Anne Bodmer Lutz, M.D.
Mental health workforce shortages combined with increased demand for services have required mental health professionals and organizations to devise innovative service delivery strategies. In emergencies and crises, the inability to offer multiple session treatment and follow-up for mental health often makes Single Session Therapy the only option. Solution-Focused Brief Therapy, an evidenced-based pragmatic approach, is an ideal method to use in Single Session Therapy.
About Single Session Therapy
Solution-Focused Single Session therapy provides an evidenced-based, trauma-informed practice that can be implemented in crisis situations. The absence of intake, triage, waiting list or assessment is key to the accessibility of single session services. Single Session Therapy has potential applications as used in emergency triage, EMS, crisis call centers, emergency settings, and where access to care can be poor (Paul & van Ommeren 2013). The World Health Organization has proposed Single Session Therapy as a potential model when responding to the Psychosocial and Mental Health needs of people who have experienced trauma. Mental health professionals have adapted the Single Session Therapy framework in emergency settings, including Hurricane Katrina, the armed conflict in Columbia, and the 2010 Haiti earthquake (WHO et al., 2012). In emergencies, Single Session Therapy can be offered as part of a specialized mental health crisis service (Miller 2010).
Single Session Therapy is not new. In 1977, a walk-in counseling center in Minneapolis, Minnesota, provided Single Session Therapy (Love, 1983). Talmon in 1990 found that at 3-12 month follow-ups, 58.6% of their sample reported that a single session had been sufficient and led to improvement in the presenting problem (Talmon and Hoyt 2014). Bernard Bloom wrote in 1981 that “Single Session Therapy would potentially be the only way for publicly funded mental health agencies to meet rising service demands and long waitlists of the future.” (Bloom, 1981).
About Solution-Focused Single Session Therapy
Solution-Focused Single Session Therapy requires the clinician to view every interaction as an intervention. Solution-Focused Single Session Therapy is intended to be pragmatic and based on the clients’ presenting concerns focusing on what the client has already done to cope and what the client wants, rather than exploring history or theories about root causes. The goal is for the client to leave with a plan and know they have the skills and resources available to move forward in a good enough way.
Can Solution-Focused Single Session Therapy reduce barriers to mental health access?
Solution-Focused Single Session Therapy promises to mitigate many of the access-to-service barriers in mental health organizations and modify the relationship between therapists and their communities. Solution-Focused Single Session Therapy can also foster a relationship with the organization providing service beyond the professionals who provide that service. Broad access to this service would enhance the mental health delivery system, provide a solution to workforce mental health shortages, and improve the quality of care in any community (Slive and Bobel 2011).
How does Solution-Focused Therapy Address the Therapeutic Common Factors?
Solution-Focused Brief Therapy is an approach that operationalizes common factors in a practical and evidence-based way that is consistent with Single Session Therapy. Research on common factors relates a positive therapeutic outcome to focus on client’s strengths and resources, a solid therapeutic alliance, focusing on client’s motivation, needs, what they want, and continually gathering feedback from the client while activating their resources (Lambert 1999, Lambert 2005, Lambert & Ogles 2014). Psychotherapy research findings suggest that most change occurs during the first couple of therapy sessions (Hansen & Lambert, 2002 & Seligman, 1995). The single-session model proposes that many people receive sufficient support from a single session with the offer of future single sessions if needed. A review of the clinical and research literature shows that between one-third and one-half of randomly selected clients seen in single-session psychotherapy report being sufficiently helped by the experience so that the therapeutic episode can be terminated (Bloom, 2001).
How does Solution-Focused Single Session Therapy Differ from Psychological First Aid?
Solution-Focused Single Session requires more in-depth training and relies upon previous clinical experience and skill sets. The purpose of Psychological First Aid is to assess the immediate concerns and needs of an individual in the aftermath of a disaster and not to provide on-site therapy.
How can Solution-Focused Brief Therapy be applied to Single Session Therapy?
The following is a practice exercise to help guide clinicians through a solution-focused single-session interview. This exercise is a learning opportunity to practice some solution-focused techniques and questions within single-session therapy.
Setting a collaborative, positive tone at the beginning of a Solution-Focused Single Session Therapy conveys confidence in the client’s abilities.
- Thank you for reaching out.
- I hope this conversation will be helpful for you.
- I will ask you several questions and will do my best within the next hour, so this session will be worth your time.
- Would this be ok with you?
Building a Yes-Set:
The yes-set is a solution-focused skill that involves creating a conversation in which both the clinician and client say yes and agree on as many aspects of the conversation as possible. “For you” statements enhance the “yes-set” while providing validation and acknowledgment of the client’s predicament. Clients and families coping with crises often experience a lack of control, exhaustion, fear, frustration, and anxiety, requiring a great deal of “for you” responses. “For you” statements are often combined with coping questions enabling clients to recognize how they have been managing.
- This must be so difficult for you; how have you been managing?
- This must be exhausting for you; how have you managed to get through even a part of your day?
- This must be so frustrating for you; how have you managed to make this even a little bit more bearable for you?
#1: RESOURCE ACTIVATION (INDIVIDUAL):
Activating resources at the onset of the conversation helps build client engagement. Resource activation co-discovers with clients aspects of their life that are satisfying. What has been working well? How have they managed in a tolerable way? Different from listing strengths, activation of resources questions in detail how clients have managed, how have they endured, where do they get their strength from, and what keeps them going? Questioning clients in-depth on their strengths co-discovers hidden resources often ignored by clients unless specifically noticed and asked.
Client’s coping with acute crises experience many challenges affecting the quality of their daily life. Asking clients what they know and have tried regarding their situation affirms their knowledge in managing their circumstances. Compliments can impart much-needed energy and stamina to both clients and their loved ones. It is important to ask questions that detail these successes.
- Tell me some things you enjoy and are good at?
- What else do you enjoy?
- How did you learn these skills?
- How have you been coping given the challenges you have been facing?
- Where do you get your strength from?
- What else has helped?
- How else did you cope?
Punctuating positive differences (Past successes)
Listening for and discovering positive differences when clients have had or are having some measure of success is crucial. Positive differences, also known as exceptions, are when the presenting problem could have occurred but did not or was less severe. These past successes may include when clients have had periods of relief from their distress- even if very brief. Perhaps they were able to manage for a moment in a tolerable way. Maybe they had the strength to work and manage their responsibilities despite their intense emotions. Perhaps they persevered in their efforts to care for their needs and those they are responsible for.
#2: RELATIONSHIP RESOURCE ACTIVATION (VIPS – MAPPING THE SOCIAL CONTEXT)
Inviting clients to identify their VIPs and what they most appreciate about them is especially critical when engaging clients who are coping with crises. Mapping out a client’s social context is essential in understanding and assisting them in building solutions from multiple perspectives expanding their relational resources.
- Who are the most important people in your life?
- What do you most appreciate about them?
- Are there people/pets you are responsible for helping care for?
- What do you most appreciate about them?
- What do you suppose they would say they most appreciate about you?
- What do you suppose they would say they know about you that you can get through this challenging time?
#3: BEST HOPES (GOAL NEGOTIATION)
“What are your best hopes for this one-hour appointment so you can say it was helpful and worth your time?” This question is future-directed, assists in goal negotiation, and conveys a belief in your client that they have best hopes. Solution-Focused Brief Therapy focuses on the client’s expertise in knowing their situation and condition best. Asking clients (and their loved ones) what they know about their condition and what they have tried helps attest to their competence. For many clients in crisis, their situation can seem out of control. Solution-focused brief therapy invites clients to focus on how they have adapted and managed to deal with their challenges in a “tolerable/bearable” way. This increases their self-efficacy in managing their situation.
Asking a client’s best hopes is only the beginning of goal negotiation. Moving from their best hopes to specific actions requires discovering with clients what they would be doing instead when they have achieved their best hopes?
- What are your best hopes (in the client’s words) that would tell you this one-hour session will be helpful for you and worth your time?
- What do you know about your best hopes?
- What do you know has helped you manage even a little bit?
- What do you know about yourself that you can achieve your best hopes?
- What do your VIPs know about you that you can achieve your best hopes?
- When was the last time things were a little better or more bearable for you?
- What have you tried to do to help?
- Supposing you achieve your best hope, what would you be doing differently?
- What would your VIPS notice you doing differently?
#4: SCALING QUESTIONS
Scaling questions invite clients to rate their goals on a numerical scale from 1-10. Scaling questions are used to rate solutions, different from many other scales which rate problems. They are developed from the client’s best hopes and can be amplified by asking patients to predict how their VIPs would rate them. Scaling questions convey empathy, are client-centered and can assist clients and clinicians in understanding perspectives from multiple viewpoints quickly. They are extremely useful in even brief Single Session Therapy encounters.
It is essential to amplify scaling questions. Working the scale provides additional opportunities to activate resources. What keeps the number from being lower? What’s the highest number it has been? What would be a good enough number? Clients often do not need the best but are very satisfied with good enough.
- Suppose 10 is you are confident in your plans to achieve your best hopes, and 1 is the opposite; where would you say you are now?
- Suppose 10 is confident you can keep yourself safe, and 1 is the opposite; where are you now?
- What would be a good enough number?
- What keeps the number from being lower?
- Suppose we asked your VIPS how confident they are in you that you can achieve your best hopes from 1-10 (10 being the best); where would they say you are?
- What do you suppose you would be doing when the number goes up by one point?
- How confident are you from 1-10 that you can take that next small step to increase your number by 1 point?
- What do you know about yourself that you can do this?
#5: END OF THERAPY SESSION FEEDBACK
In Solution-Focused Single Session Therapy, end-of-session feedback includes compliments, positive differences, VIPs, and successes co-discovered in the conversation. Scaling questions challenge clients to consider the next small steps to take toward achieving their goals. Feedback confirms that there is no other information clients think would be helpful for the clinician to know to be most beneficial for them.
- Provide a list of compliments
- Reiterate next steps that were co-discovered
- On a scale from 1-10, how helpful was this session?
- What was most helpful for you?
- Is there anything else before we end that would be important for me to know?
Click here for more information on having your organization receive training in Solution-Focused Brief Therapy Practices.
For those wishing more training in using the Solution-Focused Brief Therapy approach, you may wish to check out the following Institute online, self-paced courses:
Solution-Focused Brief Therapy: An Introduction to the Pragmatics of Hope (3 CE Credit/Clock Hours available)
Foundations of Solution-Focused Practice Online Intensive (3 CE Credit/Clock Hours available)
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