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  #1  
Unread June 29th, 2006, 06:38 PM
Nurse J Nurse J is offline
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Default Single Session/Walk-In Therapy and CBT

Hi all,

I am a mental health therapist working at a rural hospital in Northern Alberta, Canada. My job includes crisis triage in the hospital's emergency room, assessment and brief therapy in acute care, discharge planning, and fairly regular participation in weekly walk-in sessions at our local community mental health clinic.

Walk-in (single session) programs have become popular in Alberta. There is some empirical evidence to back their use, and certainly our clientele appear to appreciate the program. At last check I think the satisfaction rate was at around 98% (everyone fills out a brief survey at the completion of the session). They are seen as a way to provide service to transient populations, people with variable work schedules, and those who are cautious about commiting to therapy. These programs have typically been associated with constructivist approaches to therapy. Postmodern therapies or competency-based therapies, including Michael White's narrative therapy and solution-focused therapy, are popular in community mental health up here. But research has suggested that the specific approach has little bearing on outcome.

My question is this: Is there an established format for single-session CBT? I am also wondering if anyone has seen research related to CBT in this format. I know that most brief CBT approaches seem to emphasized a manualized system. So you'd have a few sessions with a therapist and take home a workbook (like Mind Over Mood). My own inclination is to wonder if CBT would naturally become briefer if there was greater emphasis placed on the identification and application of client factors, including patient's existing skills, knowledge, experiences resources, etc. I would welcome others' opinions about this.
Ciao!
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  #2  
Unread July 3rd, 2006, 10:01 PM
James Pretzer James Pretzer is offline
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Default Re: Single Session/Walk-In Therapy and CBT

I haven't seen much written regarding single-session CBT. I think that this is partly because CBT therapists usually hope to accomplish more than can be accomplished in a single session and partly because our clients usually hope to accomplish more than can be accomplished in a single session and are willing to come back regularly in order to accomplish their goals.

Certainly, if we know that the individual will only be available for a single contact, it will make a big difference in the focus of treatment but it will also limit what we can accomplish. You may want to see what has been written about crisis intervention from a CBT perspective. My bet is that crisis intervention is the area where CBT is most frequently used in a single-session format.

Our usual approach to providing services to transient populations, people with variable work schedules, and those who are cautious about commiting to therapy would be to be as flexible as possible in scheduling services, to try to understand and address the concerns of those who are reluctant to commit to therapy. My experience has been that it usually is possible to arrange to meet a number of times if the individual's concerns are addressed, if the advantages of repeat visits are clear to them, and if it is possible to adjust scheduling in order to take their needs and preferences into account.

You wrote that you "wonder if CBT would naturally become briefer if there was greater emphasis placed on the identification and application of client factors, including patient's existing skills, knowledge, experiences resources, etc." These are already important in CBT. Certainly, if we limited ourselves to using the individual's existing skills, knowledge, experiences, and resources this would make treatment briefer, but it also would limit what can be accomplished. It often is useful for the therapist to help the individual master new skills, acquire new knowledge, have new experiences, and acquire new resources but this does take time.
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  #3  
Unread July 4th, 2006, 08:55 PM
Nurse J Nurse J is offline
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Default Re: Single Session/Walk-In Therapy and CBT

I appreciate your reply, James. I also agree with most of what you have posted. I'll further explore the crisis counselling literature. I should note that when I see people in the walk-in program, I usually refer them to ongoing, focused counselling following the session.

That said, I believe there is some value in the single-session approach. Walk-in/single session formats are based around the idea that therapy is generally brief (3-6 sessions), with the bulk of progress occurring in the first few sessions. Some people receive enough benefit from an as-needed, single session approach, which can be supportive of self-efficacy. Sometimes the walk-in sessions (which are free) can be a safety net for people in crisis while they are on the local clinic wait-list. They can be seen much sooner and may even be given a greater priority/risk level on the list based on their walk-in session.

In terms of client factors being used, your answer doesn't surprise me because I've read some of your previous posts. You seem to have a clear understanding that your patients are much more than pathology. But how common is our approach? Christine Padesky, in her excellent article on Socratic questioning, seemed to suggest that many therapists seek to argue the client into a more adaptive way of seeing things rather than inhabiting the client's perspective and guiding discovery. Also, James Prochaska, in a self-help book utilizing his "stages of change" model, cited Aaron Beck as lamenting that some therapists were doing their clients a disservice by ignoring their personal change strategies. Is this a common problem among Cognitive therapists?
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  #4  
Unread July 24th, 2006, 08:54 PM
James Pretzer James Pretzer is offline
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Default Re: Single Session/Walk-In Therapy and CBT

I don't intend to make it sound as though I think there's no value in single session interventions. Crisis intervention, brief supportive therapy, and "triage" sessions where the therapist does a quick assessment and helps the individual make the most of the resources that are available to them can all be quite useful. However, I do think that much more can be accomplished when individuals seeking help can be seen a number of times.

Many proponents of brief therapy argue that, if therapy typically lasts 3-6 sessions, we should focus on interventions that can be completed in very few sessions. This sounds reasonable. However, should we just give up on treating problems that we can't resolve in a few sessions? Another option is to put some thought into structuring treatment in such a way that we can get people persist in treatment long enough to achieve their goals. It happens that the various CBT approaches have put considerable thought into this and do quite well at getting clients to follow through on 10-20 sessions of therapy when necessary.

You asked "You seem to have a clear understanding that your patients are much more than pathology. But how common is our approach? Christine Padesky, in her excellent article on Socratic questioning, seemed to suggest that many therapists seek to argue the client into a more adaptive way of seeing things rather than inhabiting the client's perspective and guiding discovery. Also, James Prochaska, in a self-help book utilizing his "stages of change" model, cited Aaron Beck as lamenting that some therapists were doing their clients a disservice by ignoring their personal change strategies. Is this a common problem among Cognitive therapists?" I haven't had time to look up the two articles you cite but my bet is that both Padesky and Beck were talking about non-CBT therapists or about therapists who were doing a poor job of CBT. These are not common problems among Cognitive therapists who are doing CT well.
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