Single-Session ‘One-at-a-Time’ Therapy: A Rational Emotive Behaviour Therapy Approach [1 ed.] 0367175533, 9780367175535

Citation preview

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‘This compelling and well-​ written book clearly demonstrates the benefits and timely effectiveness of the OAAT mindset for both clients and counsellors. Anyone involved in managing a counselling service with long waiting lists –​this book will be your new best friend. The dynamic approach from the author challenges more traditional counselling service models yet  allows counsellors to remain loyal to their core theoretical orientations by embedding the OAAT mindset into their practice. I have seen for myself the valuable impact on clients being able to receive help at the point of need. This was enabled by my collaborative work with the author at the Arts University Bournemouth as described in the book.’ Andy Froggett, Counselling Service Manager, Arts University Bournemouth, UK

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Single-​Session ‘One-​at-​a-​Time’ Therapy

Single-​Session ‘One-​at-​a-​Time’ Therapy: A Rational Emotive Behaviour Therapy Approach details a specific approach to Single-​Session Therapy (SST) known as ‘One-​at-​a-​Time’ (OAAT) Therapy and shows how this can be implemented from a Rational Emotive Behaviour Therapy (REBT) perspective. Windy Dryden argues that OAAT Therapy is a time-​efficient, cost-​effective means of providing help according to need. Single-​Session ‘One-​at-​a-​Time’ Therapy outlines an innovative and experimental approach to improving mental health and will appeal to psychotherapists and counsellors looking for an accessible and authoritative guide to brief therapeutic work. Windy Dryden is in clinical and consultative practice and is an international authority on Cognitive Behaviour Therapy. He is Emeritus Professor of Psychotherapeutic Studies at Goldsmiths, University of London. He has worked in psychotherapy for more than 40 years and is the author of over 225 books.

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Routledge Focus on Mental Health

Routledge Focus on Mental Health presents short books on current topics, linking in with cutting-​edge research and practice. For a full list of titles in this series, please visit https://​www.routledge. com/​Routledge-​Focus-​on-​Mental-​Health/​book-​series/​RFMH Titles in the series: Single-​Session ‘One-​at-​a-​Time’ Therapy A Rational Emotive Behaviour Therapy Approach Windy Dryden Working with Interpreters in Psychological Therapy  The Right to be Understood Jude Boyles and Nathalie Talbot Rational Emotive Behaviour Therapy A Newcomer’s Guide Walter J. Matweychuk and Windy Dryden The Feldenkrais Method for Executive Coaches, Managers, and Business Leaders Moving in All Directions Paul Ogden and Garet Newell An Evidence-​based Approach to Authentic Leadership Development Tony Fusco The Tao of Dialogue Paul Lawrence and Sarah Hill with Andreas Priestland, Cecilia Forrestal, Floris Rommerts, Isla Hyslop and Monica Manning

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Single-​Session ‘One-​at-​a-​ Time’ Therapy A Rational Emotive Behaviour Therapy Approach

Windy Dryden

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First published 2019 by Routledge 2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN and by Routledge 52 Vanderbilt Avenue, New York, NY 10017 Routledge is an imprint of the Taylor & Francis Group, an informa business © 2019 Windy Dryden The right of Windy Dryden to be identified as author of this work has been asserted by him in accordance with sections 77 and 78 of the Copyright, Designs and Patents Act 1988. All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form or by any electronic, mechanical, or other means, now known or hereafter invented, including photocopying and recording, or in any information storage or retrieval system, without permission in writing from the publishers. Trademark notice: Product or corporate names may be trademarks or registered trademarks, and are used only for identification and explanation without intent to infringe. British Library Cataloguing-​in-​Publication Data A catalogue record for this book is available from the British Library Library of Congress Cataloging-​in-​Publication Data A catalog record has been requested for this book ISBN: 978-​0-​367-​17553-​5  (hbk) ISBN: 978-​0-​429-​05740-​3  (ebk) Typeset in Times New Roman by Newgen Publishing UK

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Contents

Preface  1 Two pathways to help 

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2 Rational Emotive Behaviour Therapy: An introduction  5 3 Single-​Session Therapy and One-​at-​a-​Time Therapy: An introduction 

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4 Good practice in SST/​OAAT Therapy 

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5 Contributions from REBT to OAAT Therapy 

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6 The role of context in OAAT Therapy 

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7 REBT-​based OAAT Therapy 

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8 REBT-​based OAAT Therapy in action 

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References  Index 

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Preface

Since Moshe Talmon (1990) published his book entitled Single Session Therapy: Maximising the Effect of the First (and Often Only) Therapeutic Encounter, there has been an increasing interest in very brief therapy. The research literature shows that the most frequent number of sessions people have throughout the world is one and that the majority of people find that session useful to them (Hoyt, Bobele, Slive, Young & Talmon, 2018). When learning of these points, clinicians want to know which clients are suitable for such work and which clients aren’t. In particular, they wish to know whether Single-​ Session Therapy and very brief therapy can be used with clients with a range of diagnoses. While on the surface, these seem like reasonable questions, on closer examination it is clear that they are therapist-​centred, not client-​centred. As Jeff Young (2018) points out, it is not possible to predict accurately who will attend for one or two sessions and who will attend for more. Clients seek therapy for problems more frequently than they do for help managing diagnoses. So, while it is possible for therapists to develop an elaborate set of suitability and unsuitability criteria for single session and very brief therapy, it is clients who will generally dictate the length of their treatment and clients do not operate on such criteria. Jeff Young (2018) also pointed out that the term ‘Single-​Session Therapy’ is a misnomer. Single-​session therapists tend not to offer only one session and that is that. They offer clients the opportunity to get what they want from therapy in one session, but to have more sessions if they wish. This book follows in that tradition. ‘One-​at-​a-​Time’ Therapy is a term created by Michael Hoyt (2011) to indicate that therapists and clients should think of therapy one session at a time. If the therapist and the client can get the ‘job done’ in one session, then fine, but if not, they should see if they can do so in the next session and so on. This way of thinking of therapy encourages the client to use their strengths, resiliency factors, values and external resources in applying what they

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x  Preface learn from a given therapy session. It discourages them from thinking of therapy as ongoing and from booking sessions weeks, months or even years ahead. As Appelbaum (1975) noted, therapy expands and contracts to fill the time allocated to it (the so-​called Parkinson’s law of psychotherapy). In this book, I explore Hoyt’s (2011) concept of OAAT Therapy and in particular argue that it is important to help clients get the most from the session by encouraging them to engage in a process where, after the session, they reflect on and digest what they have learned from the session, act on this learning and then let time pass before booking a second session, if it is needed. I also show what OAAT Therapy looks like when one brings a Rational Emotive Behaviour Therapy perspective to the work. In my view, REBT lends itself very well to be adapted to therapy practised one session at a time. In this book, I  do not argue that OAAT Therapy should replace existing ways of working therapeutically. Rather, it is my view that it can complement such ways and give increasing numbers of people therapy according to need rather than therapy according to availability. This theme is explored more fully in the first chapter. I hope you enjoy and gain value from this book. Please send any feedback to me at [email protected].

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1  Two pathways to help

In recent years, I have been particularly interested in a number of therapeutic issues, many of which are being discussed in the field known as ‘Single-​Session Therapy’ or SST (Hoyt & Talmon, 2014; Hoyt et  al., 2018) As Jeff Young (2018) notes, the term is a misnomer in that most SST therapists indicate that more therapy is available to clients who need it even though the therapist and client have agreed to join forces to see if the client can get what they want from one therapeutic visit. Jeff Young (2018) urges the retention of the term ‘Single-​Session Therapy’ for its shock value and because it challenges therapists to reflect on a number of cherished beliefs that they hold about the theory and practice of psychotherapy. The term also urges therapists to think about how to provide help at the point of need rather than at the point of availability. In order to offer therapeutic assistance at the point of need, the therapist or agency in which the therapist works need to devise a helping pathway that makes it possible for the person to get help at the point when the client decides that they need it, not at the point when the therapist or agency decides that the client needs it or when it has the availability to see the person.

Two pathways to help Let’s consider two helping pathways. The first, known as ‘help at the point of availability’, is the more common while the second, known as ‘help at the point of need’ is, in my view, the more desirable. To demonstrate the difference, I will use the case of ‘Petra’, who has a problem with guilt-​based indecision. Petra has been struggling with her problem for several months. She needs to make a decision about where in the country to move to with her husband and child but has postponed this many times. She thinks that

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2  Two pathways to help whatever she decides will result in someone’s feelings being hurt:  her husband’s feelings if she moves to an area where her mother lives and her mother’s feelings if she moves to an area where her husband wants to live. She has made many lists detailing the pros and cons of each move and has sought the help and advice of her friends, all to no avail. Increasingly, she has been unable to sleep and has become irritable with her loved ones. She decides that something must be done, so she decides to seek professional help. Pathway 1: Help at the point of availability Following this pathway, Petra phones her GP practice for an appointment to see her doctor. She is asked whether or not it is an emergency and she replies, ‘no’ and is offered an appointment in three weeks’ time. She is partly relieved because she has made the first step but disappointed that she has to wait for so long. Petra’s husband says that she should have said it was an emergency, but Petra has a problem with ‘guilt’ so she could not do that! At the GP appointment, she is given ten minutes to explain what is happening and is heard sympathetically by her doctor who recognises that she needs to have what he calls ‘talking therapy’ and gives her a leaflet explaining how she can access such help. Petra is encouraged and relieved that she was not offered medication. Petra telephones the number on the leaflet which is her local Improving Access to Psychological Therapies (IAPT) service and after giving a brief explanation of her problem is told that someone will contact her soon for a telephone assessment of her problem so that she may be offered the right kind of help. She is told that she will be contacted within seven and ten working days. After seven days, she receives a message that someone from the IAPT service has rung and after playing ‘telephone tennis’, she is assessed by a Psychological Wellbeing Practitioner (PWP) trained to assess and support people with common mental health problems. She is assessed five weeks after she first decided that she needs help. The PWP worker decides that Petra has a mild-​ to-​ moderate ‘generalised anxiety disorder’ and she is offered the opportunity to join a ‘psychoeducation’ group or have guided self-​help. Petra responds by saying that she wants to have the opportunity to discuss her concerns one-​to-​one with a therapist. The PWP says that she will pass on her request and get back with a response within three working days which she does and tells Petra that her request has been granted and that she will be sent an appointment in about six weeks. This happens as

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Two pathways to help  3 planned and Petra is given an appointment to see a CBT therapist on a date and at a time that she can’t make. After several phone calls, Petra has an appointment to see a therapist two months after she was told that her request for one-​to-​one therapy had been granted. From making a decision to seek psychological assistance and being given an appointment, it has taken Petra 14 weeks to get help. Pathway 2: Help at the point of need Imagine, if you will, a situation where drop-​in centres are available throughout the UK, staffed by skilled therapists keen to help people as quickly as possible. Petra phones up her GP and is given the details of her local drop-​in service. She goes that afternoon and waits for an hour to see a therapist who is able to work with her to solve her problem with guilt that afternoon. This may seem far-​fetched, but it is not. There are such walk-​in clinics in Australia, Canada, and the USA (to name but a few) offering help at the point of need for individuals, couples and families.

This book This book fits into the brief of a Routledge Focus work in that it presents a novel approach to providing therapy services based on two major ideas: Sessions held one at a time (OAAT) and Rational Emotive Behaviour Therapy (REBT), an approach to therapy well suited to OAAT Therapy.

One-​at-​a-​Time (OAAT) Therapy in a nutshell One-​at-​a-​Time (OAAT) Therapy is a way of providing therapy services which is based on several ideas: 1. It is vital to help people at the point of their perceived need. 2. One session of therapy may be sufficient for the person seeking help. 3. More sessions are available to the person if they require additional help. 4. The person is encouraged to take time after their first (and perhaps only) therapy session to (a)  reflect on and digest what they have learned from the session, (b) take appropriate action based on this digested learning, (c) experiment with other solutions, (d) let time pass and allow things to settle down and (e) book another session if they need to.

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4  Two pathways to help 5. The client is allowed to book as many sessions as they need, but only ‘one at a time’ and after a period of reflection-​digestion-​action-​ letting time pass, as detailed above, has occurred. In other words, they cannot book a series of sessions or be in ongoing therapy. 6. Services based on the OAAT principle reduce waiting lists and allow clients within a community (e.g., a university) to be seen quickly and at times suitable for them.

Rational Emotive Behaviour Therapy (REBT) in a nutshell REBT is an approach to therapy which can be best placed within the cognitive-​behavioural tradition of psychotherapy (Dryden, 2015). Its main features are as follows: 1. It posits that psychologically disturbed responses to an adversity rest largely on a set of rigid and extreme attitudes and that psychologically healthy responses to the same adversity rest on an alternative set of flexible and non-​extreme attitudes. 2. It holds that the best way to help someone is by encouraging the person to face the adversity and to process it with their developing flexible and non-​extreme attitudes. 3. Clients can be helped to take away memorable and personalistic versions of their flexible and non-​extreme attitudes. 4. Clients can be helped to develop plans to implement their newly developed adversity-​related flexible and non-​extreme attitudes. 5. Clients sometimes have doubts, reservations and objections (DROs) to REBT concepts and practice. However, they can be helped to identify, examine and respond to these doubts.

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2  Rational Emotive Behaviour Therapy An introduction

In this chapter, I will discuss the basic theory and practice of REBT for readers who are unfamiliar with this approach to therapy. The introduction is written with OAAT Therapy in mind. Rational Emotive Behaviour Therapy (REBT) is an approach to psychotherapy that is best located within the cognitive-​behavioural tradition of psychotherapy. It was founded in the mid-​1950s by the American psychologist, Albert Ellis (1913–​2007), and was originally known as Rational Therapy (RT). Ellis changed the name of the therapy in 1961 to Rational-​Emotive Therapy (RET) to emphasise its emotive features and again in 1993 to Rational Emotive Behaviour Therapy (REBT) to emphasise its behavioural features. Here are some of its key points.

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Cognition, emotion and behaviour are interdependent processes and cannot be understood in isolation. Rigid and extreme attitudes are at the core of psychologically disturbed responses to adversity, and flexible and non-​ extreme attitudes are at the core of psychologically healthy responses to the same adversity. A central task of REBT therapists is to encourage clients to develop flexible and non-​extreme attitudes towards adversity. Meaningful psychological change is deemed to be difficult, and clients need to commit themselves to an ongoing routine of thinking flexibly and in non-​extreme ways in the face of adversity and to take action that supports and reinforces such thinking.

Terminology The terms employed in REBT have undergone revision, and I think it is critical for readers to understand these changes at the outset, as in this book I will use modern terminology.

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6  Rational Emotive Behaviour Therapy Rational Originally, Ellis used the term ‘rational’ to describe his approach to therapy to contrast it with other approaches in the mid-​1950s which de-​emphasised cognition in therapy. Towards the end of his life, Ellis remarked that he wished that he had used the word ‘cognitive’ rather than ‘rational’ to describe his approach because the term ‘rational’ can is easily be misinterpreted. However, the term ‘cognitive’ was not in common usage in the therapy world at that time, so that was not a realistic option. Despite renaming the approach twice (see above), Ellis thought that as the approach was closely associated with the term ‘rational’, it was unwise to change its name yet again. In REBT, rationality is a concept that is typically applied to a person’s beliefs (which I  renamed ‘attitudes’ in 2016, see below  –​ Dryden, 2016a). Thus, REBT therapists refer to irrational beliefs, which are deemed to be at the core of psychological disturbance and are rigid or extreme, inconsistent with reality, illogical, and both self-​and relationship-​defeating. By contrast, rational beliefs, which are deemed to be at the core of psychological health are flexible or non-​ extreme, consistent with reality, logical, and both self-​and relationship-​enhancing. From beliefs to attitudes When traditionally used in REBT, the term ‘belief’ refers to a specific kind of cognitive processing that mediates between an event (or an ongoing situation) and the person’s responses to that event (or ongoing situation). While there are problems with the term ‘belief’ (see below), it has been retained. This is, in part, because it begins with the letter ‘B’ and appears in REBT’s ABC framework showing that adversities at ‘A’ have their impact on a range of psychological responses at ‘C’ to these adversities largely because of the ‘beliefs’ that people hold at ‘B’. This is known as the ‘B-​C’ connection to be contrasted with the ‘A-​C’ connection where psychological responses to adversities are deemed to be caused by these adversities. Research that I carried out on how REBT’s ‘ABC’ framework (to be discussed in greater detail below) is understood by different professional and lay groups revealed a large range of confusions and errors made by these groups about each element in the framework (Dryden, 2013). Some of these confusions and errors about ‘B’ could, I argued (Dryden, 2016a) be cleared up by the using the term ‘attitude’ rather than the term ‘belief’. The latter, it transpires, is often used by people in a way that is very different from the way intended by REBT theory.

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Rational Emotive Behaviour Therapy  7 The term ‘belief’ has been defined by the Oxford Dictionary of Psychology, fourth edition (Colman, 2015) as ‘any proposition that is accepted as true on the basis of inconclusive evidence’. Thus, a client may say something like: ‘I believe my girlfriend is cheating on me’ and while they think that they have articulated a belief, this is not a belief as the term is employed in REBT, but rather an inference. In REBT, it is vital to distinguish between an inference at ‘A’ and an attitude (or belief in the REBT sense) at ‘B’1 and anything that helps this distinction to be made routinely is to be welcomed. Using the term ‘attitude’ rather than ‘belief’ in REBT is one way of doing so. Definitions of the term ‘attitude’ are closer to the meaning that REBT theorists ascribe to the term ‘belief’. The one that I think best captures Ellis’s ideas is as follows. An attitude is ‘an enduring pattern of evaluative responses towards a person, object, or issue’ (Colman, 2015). Before I  formally introduced this change of terminology into the REBT literature (Dryden, 2016a), I used the term ‘attitude’ rather than ‘belief’ with my clients and found that it was easier for me to convey the meaning of ‘B’ when I used ‘attitude’ than when I used ‘belief’ and they, in general, found ‘attitude’ easier to understand in this context than ‘belief’. Consequently, in this book, I will use the term ‘attitude’ instead of the term ‘belief’ to denote an evaluative stance taken by a person towards an adversity at ‘A’ which has emotional, behavioural and thinking consequences. In deciding to use the term ‘attitude’ rather than the term ‘belief’, I recognise that when it comes to explaining what the ‘B’ stands for in the ABC framework, the term ‘attitude’ is problematic because it begins with the letter ‘A’. Rather than use an ‘AAC’ framework, which is not nearly as catchy or as memorable as the ‘ABC’ framework, I now use the phrase ‘basic attitude’2 when formally describing ‘B’ in the ABC framework. While not ideal, this term includes ‘attitudes’ and indicates that they are central or basic in that they lie at the base of a person’s responses to an adversity. In using the word ‘basic’, I have thus preserved the letter ‘B’ so that the well-​known ‘ABC’ framework can be used. However, throughout the book when not formally describing the ‘ABC’ framework I will employ the word ‘attitude’ rather than the phrase ‘basic attitude’ when referring to the particular kind of cognitive processing that REBT argues mediates between an adversity and the person’s responses to it. From ‘rational’ to ‘flexible and non-​extreme’ and ‘irrational’ to ‘rigid and extreme’ In general, the term ‘rational’ is problematic because it is often seen to be synonymous with ‘robot-​like’ and ‘unemotional’. Also, the term

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8  Rational Emotive Behaviour Therapy ‘irrational’ is often seen to be synonymous with ‘crazy’, ‘aberrant’ and ‘wrong’. Given this, I decided to use the term ‘rigid and extreme’ attitudes instead of irrational beliefs and the term ‘flexible and non-​extreme’ attitudes instead of rational beliefs, and I will use these throughout this book, unless stated otherwise.

Types of attitudes As mentioned above, REBT distinguishes between rigid and extreme attitudes on the one hand and flexible and non-​extreme attitudes on the other. Rigid and extreme attitudes REBT posits that when clients respond unhealthily at ‘C’ to adversities at ‘A’ they hold a rigid (basic) attitude (e.g., ‘I want to be approved and therefore I  must be’); and one or more of the extreme (basic) attitudes:  (i) an awfulising attitude (e.g., ‘It’s bad if I’m disapproved, and therefore it’s the end of the world’); (ii) a discomfort intolerance attitude (‘It’s a struggle being disapproved, and therefore I can’t tolerate it’); and a devaluation attitude –​self-​devaluation (e.g., ‘It’s bad if I’m disapproved, and if I am it proves I am worthless’), other-​devaluation (e.g., ‘If you disapprove of me, that’s bad and proves that you are horrible’) and life-​devaluation (e.g., ‘It’s bad if I am disapproved and proves that life is all bad’). Flexible and non-​extreme attitudes REBT further posits that when clients respond healthily at ‘C’ to adversities at ‘A’, they hold a flexible (basic) attitude (e.g., ‘I want to be approved of, but I don’t have to be’); and one or more of the following non-​extreme (basic) attitudes: (i) a non-​awfulising attitude (e.g., ‘It’s bad to be disapproved of, but it isn’t the end of the world’); (ii) a discomfort tolerance attitude (e.g., ‘It’s a struggle being disapproved, but I can tolerate it, it is worth it to me to do so, and I am going to do so’); and (iii) an acceptance attitude –​self-​acceptance (e.g., ‘It’s bad if I’m disapproved, but it does not prove I am worthless. It proves I am fallible’), other-​acceptance (e.g., ‘If you disapprove of me, that’s bad, but it does not prove that you are horrible. It proves you are fallible’) and life-​acceptance (e.g., ‘It’s bad if I am disapproved, but it does not that life is all bad. Life is a complex mixture of good, bad and neutral events’).

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REBT’s situational ABC model REBT advocates a situational ‘ABC’ model of psychological disturbance and health. ‘A’ stands for adversity, which occurs within a situation and can be actual or inferred. ‘A’ represents the aspect of the situation that the person focuses on and evaluates. ‘B’ stands for basic attitude as we have seen (either flexible/​non-​extreme or rigid/​extreme). ‘C’ stands for the consequences of holding a basic attitude towards ‘A’ and can be emotional, behavioural and cognitive. Thus, ‘As’ do not cause ‘Cs’ but contribute to them. ‘Bs’ are seen as the prime but not the only determiners of ‘Cs’. Holding a flexible/​non-​extreme towards ‘A’ leads to healthy negative emotions, functional behaviour, and realistic and balanced subsequent thinking. Holding a rigid/​extreme attitude towards the same ‘A’ leads to unhealthy negative emotions, dysfunctional behaviour, and unrealistic subsequent thinking that is highly skewed to the negative.

Origin and maintenance of disturbance To paraphrase Epictetus, REBT holds that people are disturbed not by events but by the rigid and extreme attitudes that they hold towards these events. This means that while adversities contribute to the development of disturbance, particularly when these events are highly aversive, disturbance occurs when people bring their tendencies to think in rigid and extreme ways to these events. The origin of psychological disturbance REBT does not have an elaborate view of the origin of psychological disturbance. Having said this, it does acknowledge that it is very easy for humans, when they are young, to disturb themselves about highly aversive events. However, it argues that even under these conditions people react differently to the same event and thus we need to understand what a person brings to and takes from an adversity. People learn their standards and goals from their culture, but disturbance occurs when they bring their rigid/​extreme attitudes to circumstances where their standards are not met, and the pursuit of their goals is blocked. The maintenance of psychological disturbance REBT has a more elaborate view of how psychological disturbance is maintained. It argues that people perpetuate their disturbance for several reasons including the following:

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• • • • • • •

They lack the insight that their disturbance is underpinned by their rigid/​extreme attitudes and think instead that events cause it. They wrongly think that once they understand that their problems are underpinned by rigid/​ extreme attitudes, this understanding alone will lead to change. They do not work persistently to change their rigid/​ extreme attitudes and to integrate the flexible/​non-​extreme alternatives to these attitudes into their attitudinal system. They continue to act in ways that are consistent with their rigid/​ extreme attitudes. They lack or are deficient in important social skills, communication skills, problem-​solving skills and other life skills. They think that their disturbance has payoffs that outweigh the advantages of the healthy alternatives to their disturbed feelings and behaviour. They live in environments that support the rigid and extreme attitudes that underpin their problems, and they think that as this is the case, they cannot do anything to help themselves.

Theory of change REBT therapists consider that the core facilitative conditions of empathy, unconditional acceptance and genuineness are often desirable, but neither necessary nor sufficient for constructive therapeutic change. For such change to take place, REBT therapists need to help their clients to do the following:

• • • • • •

realise that they mostly create their own psychological problems and that while situations contribute to these problems, they are in general of lesser importance in the change process; fully recognise that they can address and overcome these problems; understand that their problems stem primarily from rigid/​extreme attitudes; detect their rigid/​extreme attitudes and discriminate between them and their flexible/​non-​extreme attitudes; question their rigid/​extreme attitudes and their flexible/​non-​extreme attitudes until they see clearly that their rigid/​extreme attitudes are false, illogical and unconstructive while their flexible/​non-​extreme attitudes are true, sensible and constructive; work towards the internalisation of their new flexible/​non-​extreme attitudes by using a variety of cognitive (including imaginal), emotive and behavioural change methods;

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• •

refrain from acting in ways that are consistent with their old rigid/​ extreme attitudes; extend this process of challenging attitudes and using multimodal methods of change into other areas of their lives and commit to doing so for as long as necessary.

All this is best done when effective REBT therapists develop, maintain and suitably end a good working alliance with clients (Dryden, 2015). This involves:

• • • •

therapists and clients having a good working bond; therapists and clients sharing a common view of the determinants of the latter’s problems and how these can best be addressed; therapists and clients working towards agreed goals; therapists and clients executing agreed tasks designed to facilitate goal achievement.

Skills and strategies REBT therapists see themselves as good psychological educators and therefore seek to teach their clients the ABC model of understanding and dealing with their psychological problems. They stress that there are alternative ways of addressing these problems and strive to elicit their clients’ informed consent at the outset and throughout the counselling process. If they think that a client is better suited to a different approach to therapy, they do not hesitate to effect a suitable referral. REBT therapists frequently employ an active-​directive counselling style and use both Socratic and didactic teaching methods. However, they vary their style from client to client. They begin by working with specific examples of identified client problems and help their clients to set healthy goals. They employ a sequence of steps in working on these examples which involves using the situationally based ABC framework, questioning attitudes and negotiating suitable homework assignments with their clients. Helping clients to generalise their learning from situation to situation is explicitly built into the therapy process. So too is helping clients to identify, challenge and change core rigid/​extreme attitudes which are seen as accounting for disturbance across a broad range of relevant situations. A major therapeutic strategy involves helping clients to become their own therapists. In doing this, REBT therapists teach their clients how to use a particular skill such as questioning attitudes, model the use of

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12  Rational Emotive Behaviour Therapy this skill, and sometimes give the clients written instructions on how to use the skill on their own. Constructive feedback is given to encourage the refinement of the skill. As clients learn how to use the skills of REBT for themselves, their therapists adopt a less active-​ directive, more prompting therapeutic style to encourage them to take increasing responsibility for their own therapeutic change. REBT may be seen as an example of theoretically consistent eclecticism in that its practitioners draw upon procedures that originate from other therapeutic approaches but do so for purposes that are consistent with REBT theory. REBT therapists are judiciously selective in their eclecticism and avoid the use of methods that are inefficient, or mystical, or of dubious validity. REBT therapists have their preferred therapeutic goals for their clients, namely to help them to change their core rigid/​extreme attitudes and to develop and internalise a set of core flexible/​ non-​ extreme attitudes. However, they are ready to make compromises with their clients on these objectives when it becomes clear that their clients are unable or unwilling to change their core rigid/​extreme attitudes. In such cases, REBT therapists help their clients by encouraging them to change their distorted inferences, to effect behavioural changes without necessarily changing their rigid/​extreme attitudes, or to remove themselves from adversities. In this chapter, I have introduced REBT to enable you to have a basic understanding of this approach so that you can see in later chapters how it can be adapted to OAAT Therapy.

Notes 1 Briefly, an inference is a hunch that a person makes regarding an event, which may or may not be true, but is often treated as true by the person. An attitude, as we will soon see, is an evaluative stance that the person takes towards that inference. 2 As suggested by my good friend and colleague, Walter Matweychuk.

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3  Single-​Session Therapy and One-​at-​a-​Time Therapy An introduction

Moshe Talmon (1990), an Israeli psychologist, published a book on Single-​Session Therapy which brought together earlier disparate efforts to single-​session work with clients and which launched widespread interest in this field. This interest led to developments in both Single-​ Session Therapy by appointment and by walk-​in worldwide, particularly in Australia and Canada where the first two international symposia on this subject took place: Melbourne, Australia in 2012 (Hoyt & Talmon, 2014)  and Banff, Canada in 2015 (Hoyt et  al., 2018). My interest in single-​session work was piqued by these developments but began further back, with Albert Ellis’s single-​session demonstrations of REBT in front of an audience with volunteers from that audience in what came to be known as the Friday Night Workshop1 (Ellis & Joffe, 2002).

Terminology Single-​Session Therapy (SST) It is recognised that Single-​Session Therapy (SST) is a confusing term (e.g., J.  Young, 2018). Some people take it to mean a planned single-​ session of therapy where no other sessions are possible, while others stress that it involves a decision between therapist and client to attempt to get the work done in one session, but that more sessions may be available if needed. The latter is the dominant view in the field. One-​at-​a-​Time (OAAT) Therapy Michael Hoyt (2011) introduced the term ‘One-​at-​a-​Time’ Therapy to the literature and recently stated that ‘one-​at-​a-​time doesn’t necessarily mean only one time’ (Michael Hoyt, personal communication, 4 May 2018). OAAT Therapy can be seen as a Single-​Session Therapy

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14  Single-​Session Therapy and OAAT Therapy in that the intention is to help the person get what they are looking for from the initial session so that they can get on with their life on their own, secure that they can return in the future to have another session. However, and this is my own contribution, they are first asked to commit to a period of reflection, digestion, action and letting time pass. As noted in Chapter 1, there are a number of features of OAAT Therapy

• •

• • •

The client has a session of therapy. The client is encouraged to take time after this session to: (a) reflect on and digest what they have learned from the session; (b)  take appropriate action based on this digested learning; (c) experiment with other solutions; and (d)  let time pass and allow things to settle down. At the end of this period, the client decides whether or not to book another session. If they have another session, the same process is followed as above. The person can only book one session at a time. They cannot book a series of sessions.

OAAT Therapy is consistent with what Cummings (1990) called ‘brief intermittent psychotherapy through the life cycle’. Here, a person would seek therapy when they had a problem which they could not solve by themself. They would leave therapy when they felt able to address the problem independently. The OAAT framework allows the person to address their problem one session at a time, to come and go as they please and to have another session whenever they feel that they can benefit from it.

The single-​session mindset in action It is generally agreed in the SST/​OAAT community that what links all variants of SST/​OAAT Therapy is what has been called the ‘single-​ session mindset’ (Hoyt & Talmon, 2014) whereby therapist and client will approach the session as if it will be the only session that they will have. In some settings, therapist and client have some contact before they meet for the single session so that the client is helped to get the most from the single session, but in other contexts (such as walk-​in services) they don’t. The following action-​based elements of the single-​ session mindset constitute, in my view, a good introduction to SST/​ OAAT Therapy.

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Single-​Session Therapy and OAAT Therapy  15 Celebrate the power of ‘now’ and create an expectation for SST/OAAT Therapy Rather than be intimidated by the limited time at their disposal, SST/​ OAAT therapists acknowledge the power of ‘now’, recognise that change can occur in the moment and utilise the present to co-​create with the client an opportunity for the latter to change. Part and parcel of celebrating the power of now is to create suitable expectations for the client. For example, Battino (2014) discusses the fact that almost all his clients for the past few years have been for one session. In creating expectations for SST, Battino (2014: 394) tells his clients at initial contact that ‘I rarely see people for more than one or two times and that I will do everything that I can so that it is only one session’. Develop an end-​of-​session focus Unlike in regular therapy where a therapist may ask a client what their treatment goals are, the SST therapist will ask a client what they want to achieve from the session. For example a therapist might ask, ‘If when you reflect on our session this evening you think that it has made a real difference to your life, what would you have achieved that would have led you to this conclusion?’ or ‘If we work hard together in this session to help prepare you to take a significant step towards achieving your goal, what would that step be?’ The SST/​OAAT therapist knows that they may not see the client again and therefore working together so that the client has a direction to take forward after the session is critical. Agree on a focus in the session Once it is clear what the person wants to achieve from the session, the therapist helps them to create a focus that enables them to work towards that goal. This may involve them discussing their problem and working with the therapist to address it effectively, or it may involve the therapist and client adopting more of a solution orientation. Keep on track Once a focus for the session has been agreed between the therapist and client, the therapist checks periodically that they are both on track and are still dealing with the client’s main concern. If not, the therapist helps to re-​orient the client. Even if a therapeutic focus has been agreed, given

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16  Single-​Session Therapy and OAAT Therapy a person’s natural tendency to wander off track, the therapist helps them to stay with the agreed focus throughout the session, interrupting them if necessary –​and if so always with tact and sensitivity. Utilise client strengths SST/​OAAT therapists are united in the view that clients have the necessary wherewithal to solve their problems quickly with focused help from the therapist. Thus, SST/​OAAT therapists use every opportunity to encourage clients to use their strengths in the service of change. Negotiate a solution SST/​OAAT therapists hold that negotiating a solution with clients is a defining feature of SST/​OAAT Therapy. This is the case whether the therapist is working on their own with a client or whether an observing and reflecting team are involved. Possible solutions are put to the client and negotiated with them. A good example of this is to be found in a chapter by Keeney and Keeney (2014) where Brad Keeney is consulting on treatment options with the family of a 13-​year-​old boy (not present in the interview) who had been checked into a local psychiatric facility. In deconstructing the sessions, Keeney and Keeney (2014: 450) make the point that any diagnosis and prescription for treatment, whether it’s boot camp, pills, religion, reflects the particular worldview of the person offering the advice rather than absolute truth. Interactionally speaking, Brad has created a context inside which he can share his opinion freely as one of many possible views while acknowledging the leadership of the parents as the ones that must ultimately navigate all the different professional advice they receive. Provide and/or utilise resources It is also generally accepted that in addition to using a client’s internal strengths in the service of their single-​session goals, it is crucial to help them see that they can also draw on relevant environmental resources, in particular, those people who can provide support as they implement the negotiated solution. Clarify next steps It is vital that a client leaves a single session with possible next steps clarified. Thus, it is generally regarded to be a good idea for a client to

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Single-​Session Therapy and OAAT Therapy  17 know if further help is available and how they can access that help. In the OAAT service provision that I will be discussing in this book, the client leaves knowing that they can book another session should they need it, but they are first encouraged to reflect on and digest what they learned from the session and then to implement the solution that they negotiated or any other action plan. When they have done this and have waited for things to settle down, then they are best placed to judge whether or need they need another session.

My own applications of SST From these influences, I  have developed three ways of working in a single-​session context. In the first, which I  have called Single-​Session Integrated Cognitive Behaviour Therapy (SSI-​ CBT), I  offer (a)  a pre-​session contact (normally by telephone) to help the client get the most out of the face-​to-​face session that follows; (b) a 50-​minute face-​ to-​face session; and (c)  a telephone follow-​up session usually three months later (Dryden, 2017). In the second, which I have called Very Brief Therapeutic Conversations (VBTCs), I  conduct demonstration-​ based sessions in front of an audience that last for up to 30 minutes with volunteers whom I have never met before and will probably never meet again (Dryden, 2018). The third is my work in OAAT Therapy and forms the subject of this book In all these ways of working, my practice is influenced by REBT and in Chapter  5, I  will outline what REBT has to contribute to OAAT Therapy. Before that in Chapter 4, I will outline what the SST literature has taught me about the practice of OAAT work.

Note 1 The Albert Ellis Institute has carried on Albert Ellis’s work in this area after his death in 2007, at what is now called ‘Friday Night Live’.

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4  Good practice in SST/​OAAT Therapy

As in other therapeutic areas, there are differences of opinion about the practice of SST/​OAAT Therapy. However, there is also a great deal of consensus about its practice, and before I discuss what REBT has to offer the practice of OAAT Therapy, I want to outline what is considered to be good practice of Single-​Session Therapy (Dryden, 2019a) and therefore good practice in OAAT Therapy. In doing so, I will comment on REBT’s general position on each point to show how well it serves as an approach to OAAT Therapy. You will see that there is already a close agreement between SST/​OAAT Therapy and REBT on many of the following points.

Agree why we are here and what can we do In SST, it is crucial that the therapist and client have an understanding before they begin the session concerning the time that they have at their disposal and what additional help is available to the client if more is needed. In OAAT Therapy this means that the therapist and the client work productively together in a focused way to help the client get what they want from the session. The client understands that sessions can only be booked one at a time and that they should reflect on and digest what they learned from the session, implement any plans they agreed with the therapist and see what happens before booking another session. In terms of what can be realistically achieved in the time that the client and therapist have available, it depends on the nature of the client’s problem and what their goal is. In my view, Single-​Session Therapy is particularly suited for people who are emotionally ‘stuck’ and would like some help to get ‘unstuck’. In this case, OAAT Therapy can help the person take the first step in getting unstuck and further sessions, if needed, can help the person deal with any difficulties experienced along this path.

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Good practice in SST/​OAAT Therapy  19 The REBT position REBT therapists also generally advocate the importance of making explicit agreements with their clients. Explicitness is a key therapist characteristic in REBT, so REBT therapists would have no difficulty in clearly detailing the nature, possibilities and constraints of OAAT Therapy.

Engage the client quickly through the work Because in SST/​OAAT Therapy time is, by definition, at a premium (Dryden, 2016b), the therapist needs to get down to work with the client straightaway and build a working alliance through the work. This means that there is little time for pre-​work alliance-​building activity and indeed no time for a lengthy case formulation. Simon, Imel, Ludman and Steinfeld (2012) in a research study found that clients who had a good outcome from SST had a good working alliance with their therapists, whereas clients who did not have a good outcome from SST did not develop a good alliance with their therapists. This shows that it is possible to work effectively with clients in SST/​OAAT Therapy and develop a working alliance through the work. In a book that I did on a series of very brief therapeutic conversations that I  carried out in India (Dryden, 2019b), the feedback from the volunteers mentioned my relational contribution to the conversation as much as my technical contribution. It seems as if effective SST/​ OAAT Therapy occurs when the relational contribution of the therapist complements their technical contribution. The REBT position In general, REBT therapists tend to get down to work as soon as a client attends for the first session and rather than carry out a pre-​ treatment case formulation, they construct one as problem-​focused therapy develops. Many years ago, Albert Ellis used to leave cassette recordings of his therapy sessions for Institute fellows and visiting therapists to listen to. I listened to numerous of these sessions, many of them first sessions, and they were characterised by a ‘let’s get down to business’, problem-​focused approach to therapy. Consistent with an OAAT approach, at the end of the session, Ellis invited the client to make another appointment at the front desk when they were ready to.

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20  Good practice in SST/​OAAT Therapy

Be prudently active Being prudently active in SST/​OAAT Therapy involves the therapist being active themself while promoting client activity rather than rendering the client passive. The SST/​OAAT therapist does this by encouraging  the client to be focused on their problem and/​or their goal, to share what they already have done to try to solve their problem and what the outcome of these attempts were and to make clear what they want from the session. A  good example of therapist activity encouraging client activity is found in the questioning methods that solution-​focused therapists use with their clients (see Ratner, George & Iveson, 2012). The REBT position Being prudently active is precisely what good REBT therapists strive to do with their clients in ongoing REBT. An effective REBT therapist does this in two ways. First, they strive to engage their client in a Socratic dialogue whereby they ask the client open-​ended questions designed to encourage the person to think through a variety of issues for themselves. Second, if they do have to use didactic methods (when Socratic dialogue fails, for example), they make sure that the client is actively involved by asking them to put into their own words the concepts that they are being taught and to share their doubts, reservations and objections to these ideas.

Be focused and help the client stay focused Creating and maintaining a focus in the session are important ingredients of the SST mindset as discussed in Chapter 3. If the client in SST/​OAAT Therapy is not actively helped to focus and stay focused then their attention will roam more widely, and this will limit what they will achieve from the single session. The REBT position Encouraging the client to be focused is very much an integral part of REBT. While there may be times when the REBT therapist will encourage their client to explore in a more open-​ended way, generally they encourage the client to engage in focused exploration of their problems. This involves interrupting the client tactfully when necessary.

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Good practice in SST/​OAAT Therapy  21

Elicit the problem from the client’s perspective Not all SST therapists take a problem-​focused as well as a solution-​ focused approach. However, for those who do, it is vital to understand how the client sees the problem, before or while assessing the client’s problem utilising whatever professional assessment framework the therapist employs. The REBT position REBT therapists distinguish between the client’s ‘problem-​ as-​ experienced’ and their ‘problem-​as-​assessed’. It is valuable for the client to sense that their REBT therapist understands the former before they work together on the latter (Dryden, DiGiuseppe & Neenan, 2010).

Assess the problem1 If the SST therapist suggests an assessment of the client’s problem based on a particular professional framework, then they need to make this clear, and it should preferably be agreed with the client before proceeding. It is wise for the therapist to incorporate the client’s views into the assessment unless doing so will interfere with the client’s well-​being. The REBT position REBT therapists would agree with this as a general point. They tend to use an ABC framework to help clients make sense of their problems and how they can best address problems (see Chapter 2), but some like Ellis (1989), for example, regard the practice of incorporating clients’ views as amounting to ‘ineffective consumerism’ and thus to be avoided.

Elicit the client’s goal/​preferred future and keep focused on this It is perhaps difficult to think of an approach to SST that would not be goal/​future-​focused. Steve de Shazer (1991: 112), for example, specified that workable goals in brief therapy have the following features. They should be: (a) small rather than large; (b) salient to clients; (c) described in specific, behavioural terms; (d)  achievable within the practical contexts of clients’ lives; (e) perceived by the clients as involving ‘hard work’; f) described as the ‘start of something’ and not as the ‘end of something’; and g) treated as involving new behaviour(s) rather than the

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22  Good practice in SST/​OAAT Therapy absence or cessation of existing behaviour(s). These are also valuable guidelines for goals in SST/​OAAT Therapy. Given this future emphasis, the SST therapist looks for every opportunity to help their clients to ‘bridge’ to the future from discussions about the past or present. The REBT position The REBT therapist, in general, is happy to discuss their client’s problem within the chosen timeframe of the client. However, in doing so, they will take the position that if the client is disturbed about the past/​present/​and anticipated problem, it is because they are disturbing themself now about this problem. However, the REBT therapist would have little difficulty in helping the client to identify and deal with future examples of their problem, and as time is at a premium in SST/​OAAT Therapy, the REBT therapist is comfortable with this ‘bridging to the future’ principle. Concerning goal focus, REBT therapists tend to favour negotiating goals with clients related to addressing their disturbance before negotiating development-​related goals, since the latter goals are unlikely to be achieved if the former are not met first. It is crucial that the REBT therapist summarise periodically to keep this process on track and keep the momentum going. While other SST/​OAAT therapists tend not to make this REBT-​based distinction between disturbance-​ related goals and development-​related goals, both sets of therapists agree on the value of staying focused on goals once they have agreed with clients.

Ensure that the future focus is underpinned by a value, if possible When the client is helped to see that one (or more) of their important values underpin their SST/​OAAT Therapy goal, they will tend to pursue their goal even when the going gets tough. If the therapist helps the client to identify such a value, they encourage them to keep this mind when working both in the session and after the session. The REBT position With one significant exception, there is not much written in the REBT literature on values and their use in REBT. That exception concerns the values to be found in the criteria of mental health outlined by Ellis

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Good practice in SST/​OAAT Therapy  23 (1994). Bernard (2018) calls these rational principles of living, and they include:  enlightened social interest; social interest; self-​direction; unconditional self-​acceptance; tolerance of others; balance between short-​and long-​range hedonism; commitment to absorbing interests; healthy risk-​taking and experimentation; discomfort tolerance and grit; problem-​solving; and flexibility and scientific thinking. In SST/​OAAT Therapy, the REBT therapist could help a client to nominate such a principle that would encourage movement towards their goal, particularly after the session has come to an end. This would form part of the reflection-​digestion-​action-​let time pass process in OAAT Therapy.

Explain interventions whenever practicable It is vital that the client understands fully what is going on in the session, and thus good SST/​OAAT therapists explain as much as is practicable what they are doing and why. One reason for doing so is to gain the client’s informed consent. Another reason is to give the client an opportunity to modify add to or cast doubt on the intervention since if the person is not fully signed up to what the therapist intends or what the therapist is suggesting for their use, then the intervention will not yield much benefit. The REBT position REBT therapists would generally go along with the value of being explicit in therapy. For example, it is useful for the therapist to explain the purpose of examining unhelpful attitudes that are at the base of the person’s problematic response to the adversity that features in their problem (i.e., the ‘B’ in the ABC problem assessment).

Encourage the client to be as specific as possible but be mindful of opportunities for generalisation The value of the client being specific in SST/​OAAT Therapy is that when they do so, it helps to engage their emotions and thus they will provide clinically relevant information with which they and their therapist can productively work. In addition, such information facilitates healthy emotional processing in the session. However, it is also vital for SST therapists to help their clients to generalise such specific learning more widely in their life if this is possible and they will look for opportunities to do so.

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24  Good practice in SST/​OAAT Therapy The REBT position An effective REBT therapist is typically good at moving forwards and backwards along the specific–​general therapeutic continuum and at helping their clients do the same. While in ongoing REBT specificity occurs at the beginning and generalisation later in the process, if the REBT therapist is flexible enough and the client can be engaged accordingly then good specific work can be done in OAAT Therapy while taking advantage of any opportunities for generalisation that are presented.

Identify and encourage utilisation of client strengths SST/​OAAT therapists stress the importance of moving away from the usual focus of therapy on client weaknesses and problems to client strengths and solutions, and as such, a deliberate attempt is made by the SST therapist to do this early on in the session (e.g., K. Young, 2018). This is a practical implementation of the SST mindset known as ‘client empowerment’. The REBT position While this is not a subject that is commonly discussed in the REBT literature, there is nothing in REBT theory to prevent the focus on client strengths and solutions. This is a good example of how the general practice of REBT could be enhanced by insights from the SST/​OAAT Therapy literature.

Identify and encourage utilisation of external resources The SST/​OAAT therapist considers that the client’s environment can be helpful to the person in solving their problem, and thus they encourage their client to utilise such external resources while discussing potential solutions. An example of such a resource would be people supportive of the client. The client might ask this group of supporters to encourage them as they strive towards their goal. The REBT position REBT therapists are, in general, sceptical about solutions that utilise external resources unless these are based on client attitude change. However, given that a core characteristic of the effective REBT therapist is flexibility if they recognise that attitude change is not possible

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Good practice in SST/​OAAT Therapy  25 they might utilise other therapeutic ingredients, and these might include the use of external resources. Ellis (2002) made this point cogently in his book on dealing with client resistance.

Identify previous attempts to solve the problem The efficient use of time is of the utmost importance in SST/​OAAT Therapy, and thus the therapist seeks to understand what the client has already tried to solve the problem. Having done this, the therapist urges the client to use those strategies that have been helpful to them and to avoid using strategies that have proven to be unhelpful. The REBT position This is not incompatible with the general practice of REBT so long as capitalising on successful past strategies does not mean that the therapist cannot encourage client attitude change in SST/​OAAT Therapy.

Make liberal use of questions An SST/​OAAT therapist tends to ask their client a lot of questions, as this is the best way of encouraging the client to identify and keep their focus on realistic goals. However, it is good practice for such therapists to give their clients time to answer these questions and ensure that they answer the questions that they have been asked. The REBT position REBT therapists also ask their clients a lot of questions in ongoing therapy and do so using the two safeguards mentioned directly above.

Ensure client understanding and agreement In SST/​OAAT it is vital that the therapist ensures that any substantive points that they want the client to grasp are, in fact, understood by the client. This is particularly the case if a team-​based approach is being employed in SST/​OAAT Therapy and the team communicates through the therapist something it wants the client to understand and implement. Given this, it is crucial that the therapist asks the client to put their understanding into their own words so that its accuracy can be properly ascertained. While important, gauging that a client has accurately understood a concept is only half the story. Assessing whether or not the client agrees

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26  Good practice in SST/​OAAT Therapy with the concept is the other half of the story. Just because a client accurately understands a concept does not mean that they agree with it. So, both issues are important to cover in SST/​OAAT Therapy. The REBT position The REBT therapist considers that ensuring that a client understands and agrees with a concept are fundamental therapist tasks in REBT as they are in SST/​OAAT Therapy. REBT is rich in concepts and uses terms in particular ways that in general usage may have different meanings. So, it is essential to check to see if the client gets what their therapist intends for them to get. For example, the terms, ‘acceptance’ and ‘awful’ both have a specific meaning in REBT theory that can easily be misunderstood and need to be clarified with clients.

Identify and respond to the client’s doubts, reservations and objections (DROs) As time is at a premium in Single-​Session Therapy, the therapist needs to be alert for signs that the client has doubts, reservations or objections (DROs) about what is being discussed. These need to be dealt with as quickly as possible or a more acceptable tack be taken. The REBT position REBT therapists routinely look for and deal with clients’ DROs about relevant REBT concepts and their implementation, although they would be reluctant to change tack until every reasonable avenue in addressing a particular DRO has been explored (Dryden, 2001). There might not be sufficient time to do this in SST/​OAAT Therapy, and thus, the REBT OAAT therapist would need to be flexible in terms of how comprehensive such exploration can be.

Make an emotional impact It is crucial that clients in SST/​OAAT Therapy are emotionally engaged in the process as quickly as possible, but the therapist needs to guard against the client being flooded with emotion. Too much emotion and the client will not be able to think, too little emotion and they will only be engaged intellectually. While making an emotional impact is important, the therapist should not push for it, as the more they push for such an impact, the less likely it is to occur.

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Good practice in SST/​OAAT Therapy  27 The REBT position The REBT therapist is also mindful that it is important to engage their client’s emotions in therapy, otherwise the therapeutic discussion can become overly theoretical. I  recognised this danger many years ago when I proposed the use of a range of what I called ‘vivid’ methods in REBT. These methods are designed to increase the emotional impact of rational concepts during therapy sessions (Dryden, 1986).

Encourage the client to take one meaningful point from the single session There is a danger that, in their keenness to help the client get the most out of the process, the SST/​OAAT therapist ends up by overloading the client with too many therapeutic ‘goodies’ (Dryden, 2019a). It is far better to help the person take away one meaningful point which they have a plan to implement as soon after the session as practicable (Keller & Papasan, 2012). The REBT position The REBT therapist would agree with this point since in ongoing therapy the client is more likely to carry out a homework assignment when this is based on one piece of significant learning in a therapy session than they would be if they agreed to do several such assignments based on several pieces of in-​session learning.

Encourage the client to practise the solution in the session In order to build a bridge between the client’s selected solution and its later implementation, the therapist encourages the client to practise this solution in the session where feasible. In doing so, the client has an opportunity to get a ‘feel’ of the solution and to make a more informed decision to implement it if the ‘feel’ is right. Such practice also gives the client and therapist an opportunity to ‘tweak’ the solution if necessary or even to change it if it proves to be unworkable. The REBT position The REBT therapist utilises such in-​session practice with their clients in their ongoing work using role play, chairwork and imagery methods, among others.

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28  Good practice in SST/​OAAT Therapy

Strive to end the session on an encouraging note At the very end of the session, the SST/​OAAT therapist encourages the client to summarise what they will take away from the session, adding any crucial points the client missed, ties up any loose ends, discusses the possibility of another session or sessions with the client and plans a possible follow-​up session. It is good practice for the therapist and client to end the session on a high note so that the client is geared up to implement their learning as soon as possible. The REBT position The REBT therapist would also encourage optimism at the end of sessions in ongoing therapy as long as it is appropriate to what the client has been discussing in the session and the optimism is not false. In the next chapter, I will discuss the contributions that REBT has to make to OAAT Therapy.

Note 1 This position is taken by therapists adopting what Hoyt et al. (2018) refer to as ‘active-​directive’ approaches, but not necessarily by therapists adopting what they refer to as ‘constructive’ approaches.

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5  Contributions from REBT to OAAT Therapy

Having reviewed good practice in SST/​OAAT Therapy and shown that many of the points discussed are shared by REBT therapists in their general practice of REBT, I  will now discuss how REBT might contribute to good practice in OAAT Therapy.

Adopt an adversity focus One of the strengths of REBT, in my view, is that it encourages the client to focus on adversity even if the adversity as the client sees it is represented as a distorted inference. For example, a client may say that they are anxious about being ridiculed at a party. It may be that the therapist might consider that this is unlikely given the circumstances and might be tempted to help the client to examine the likelihood of this event happening or to understand why they have made such a distorted inference. While the REBT-​ based OAAT therapist would not be against helping the client to examine and change a distorted inference in favour of a more realistic one, and the temptation to doing this within the time constraints of SST would be substantial, this would not be their first line strategy. Thus, especially when it is clear that the person has had problems dealing with an adversity in many situations, the REBT-​based OAAT therapist would encourage the client to focus on the adversity and assume that it is true, for the time being, so that they can both work on developing a healthy response to the adversity. Common adversities that clients discuss in REBT-​ based OAAT Therapy include problematic relationships with others, failure, rejection and/​or negative evaluation, uncertainty in the context of threat, lack of control, frustration and goal obstruction (Dryden, 2018).

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30  Contributions from REBT to OAAT Therapy

Help the client set goals in response to the adversity As I mentioned in Chapter 3, OAAT Therapy is goal focused. The goal that the client sets in REBT-​based OAAT Therapy depends on when the therapist asks for it. At the very outset, the client’s goal will tend to be general and positive and usually bypass the adversity, while at the end of the assessment, it will be in relation to the adversity. In my view, the REBT-​based OAAT therapist’s job is to help the client set realistic, achievable goals with respect to the adversity that is at the core of their problem as shown in the example below.

Use the ABC framework What the REBT-​based OAAT therapist brings to the OAAT Therapy process are the REBT views of emotional problems and their resolution. As I  discussed in Chapter  2, the ABC framework shows that the person’s problem is usually experienced as unhealthy negative emotional responses and dysfunctional behavioural responses at ‘C’ to an adversity at ‘A’ that is at the heart of the person’s problem. The reason for the person’s disturbed reaction to the adversity is because they hold a set of rigid and extreme attitudes towards this adversity. The REBT-​based OAAT therapist also uses the ABC framework as a way of offering the client a solution to their problems. Given the time-​limited nature of OAAT Therapy, such time that is available is best spent by the therapist helping the client to work towards developing constructive emotional and behavioural responses at ‘C’ to the same adversity at ‘A’. They do this by helping the client to initiate attitude change at ‘B’. The REBT-​based OAAT therapist is flexible if the client indicates that they don’t find focusing on attitude change useful. In this case, they may help the client change their inference at ‘A’, change the situation itself in which the adversity is located, reframe the situation or change their behaviour towards the adversity. The REBT-​based OAAT therapist is quite at home in working with a specific example of the client’s problem and does so because it helps bring to the fore clinically relevant information about the ABC components of their problem. In my experience, time is best used in OAAT Therapy working with an example of the problem that is likely to occur imminently. The reason for this is that the client can begin to deal with the same example that they have discussed with the therapist. The transition between learning and application is thus smooth. If the therapist and client work with a past example of the client’s problem, then they would still have to find an anticipated one to which the client can apply their learning. Let me provide an example. Fran was struggling with her studies and said she was stressed. Initially, she said that she wanted to enjoy

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Contributions from REBT to OAAT Therapy  31 studying again. I  asked her to select an example of her study ‘stress’ problem that was likely to occur imminently. She chose a meeting that was set to occur in a few days where she was due to get feedback on a draft of her dissertation from her supervisor. The assessment of this example of the problem is outlined in Table 5.1.

Table 5.1 ABC example with Fran Situation Going to a meeting where my supervisor is going to give me feedback on a draft of my dissertation Adversity (‘A’) My supervisor will criticise my draft Basic Attitudes (‘B’) (Rigid and extreme)

Basic Attitudes (‘B’) (Flexible and non-​extreme)

She must not criticise my draft

I don’t want her to criticise my draft, but that does not mean that she must not do so

If she does, it proves that I am a failure

If she does, it does not mean I am a failure even if my draft isn’t very good. It means I’m fallible

Consequences (‘C’) (Unhealthy and dysfunctional)

Consequences (‘C’) (Healthy and functional)

Emotional = Anxiety

Emotional = Concern

Behavioural = Feeling like giving up my studies

Behavioural = Resolving to improve the draft

Cognitive = ‘I will never get my degree’

Cognitive = ‘If she criticises my draft, I may not get my degree, but it is much more likely that I can use her feedback to improve my dissertation and thus increase the chances that I will get my degree’ These serve as potential adversity-​ related goals for Fran

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32  Contributions from REBT to OAAT Therapy In my practice of REBT-​based OAAT Therapy, I  spend the most time trying to identify what the client is most disturbed about at ‘A’ (i.e., the adversity) and helping the client to set and commit to a realistic adversity-​related goal at ‘C’.

Identify the ‘A’ Finding out and working with what the client is most disturbed about in a specific example of their problem is, in my view, crucial in REBT-​ based OAAT Therapy. Doing so gives a real emotional focus to the work. I  developed a rapid way of doing this, which I  have called Windy’s Magic Question. This is time-​efficient and thus particularly suitable for use in SST. I present how I used this method with Fran in Table 5.2. Table 5.2 Windy’s Magic Question (WMQ) with Fran The purpose of this questioning technique is to help the client to identify the ‘A’ in the Situational ABC framework as quickly as possible (i.e., what the client is most disturbed about) once ‘C’ has been assessed, and the ‘situation’ in which C has occurred has been identified and briefly described. Step 1. I asked Fran to focus on her disturbed emotional ‘C’ (here, ‘anxiety’). Step 2: I then asked her to focus on the situation in which ‘C’ occurred (here ‘going to a meeting where my supervisor is going to give me feedback on a draft of my dissertation’). Step 3: I asked Fran: Which ingredient could we give you to eliminate or significantly reduce ‘C’ (here, anxiety)? (In this case, Fran said ‘my supervisor not criticising the draft of my dissertation’). At this point, I took care that Fran did not change the situation (i.e., she did not say: ‘not going to the feedback meeting with my supervisor’). Step 4: The opposite is probably ‘A’ (e.g., ‘my supervisor criticising the draft of my dissertation’), but I checked to see if this was the case. I asked: So when you are going to the feedback meeting with your supervisor, are you most anxious about her criticising your dissertation draft? If not, I would have asked the question again until Fran confirmed what she was most anxious about in the described situation.

Help the client to set a meaningful and realistic adversity-​based  goal This is probably the most difficult task that the REBT-​based OAAT therapist has. As discussed earlier, the client often wants to bypass the

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Contributions from REBT to OAAT Therapy  33 adversity in setting a goal. In response, the therapist needs to help the client understand that the best way to achieve this goal is first to set and achieve an adversity-​related goal. In this regard, I helped Fran see that for her to be stress-​free in her studies, she first had to be concerned, but not anxious about her supervisor’s criticism of her dissertation draft (see Table 5.1).

Emphasise choice of attitude In helping the client to identify the attitudinal core of their problem and the solution to this problem. I  developed a technique called Windy’s Review Assessment Procedure (WRAP) which I outline in Table 5.3 and is self-​explanatory. This helps the client see that they have a choice of attitude and that one leads to their problem and the other if adopted, would lead them to achieve their goal.

Engage the client in meaningful questioning of both attitudes When it comes to helping the client to question their respective attitudes, it is important that the therapist work quickly, yet powerfully. The goal of this part of the work is to encourage the client to commit to developing the flexible/​non-​extreme attitude rather than the rigid/​extreme attitude. Effective methods that can be employed here include asking the client which attitude they would teach a child or friend to develop while facing the ‘A’ and which attitude they wished they were taught growing up. The therapist encourages the client to give reasons for their choice and then shows them that they have another choice to make. They can choose to apply the recommended attitude to themselves or not. If they express scepticism about applying the recommended attitude to themselves, it is worth spending some time exploring and dealing with such reluctance.

Encourage attitude-​based practice of the solution in the session If possible, it is a good idea if the REBT-​based OAAT therapist helps the client to rehearse their flexible/​non-​extreme (healthy) attitude in the session as recommended by SST/​OAAT therapists (see Chapter 4). Techniques employed here include imagery, role play and REBT-​based chairwork. In such chairwork, the client engages in a debate between healthy and unhealthy attitudes as personified by different parts of themselves or where the unhealthy attitudes are personified by significant attitudes. Here, the REBT-​based SST/OAAT therapist is best engaged in being an active supporter of the client as the latter strives to practise the healthy attitude, as recommended by Kellogg (2015).

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34  Contributions from REBT to OAAT Therapy Table 5.3 Windy’s Review Assessment Procedure (WRAP) with Fran Purpose: Once ‘C’ (e.g., ‘anxiety’) and ‘A’ (e.g., ‘my supervisor criticising the draft of my dissertation’) have been assessed, this technique can be used to identify both Fran’s rigid and alternative flexible attitude and to help her understand the two relevant B-​C connections. This technique can also be used with any of the derivatives of the rigid and flexible attitude pairing. In the example below I worked with Fran’s self-​devaluation attitude and her alternative unconditional self-​acceptance (USA) attitude. Step 1: I said: Let’s review what we know and what we don’t know so far. Step 2: I then said: We know three things. First, we know that you were anxious (‘C’). Second, we know that you were anxious about your supervisor criticising the draft of your dissertation (‘A’). Third, we know that your goal with respect to the problem is to feel concerned, but not anxious about your supervisor’s criticism. Step 3: Now, I say: Now let’s review what we don’t know. This is where I need your help. We don’t know which of two attitudes your anxiety is based on. So, when you are anxious about your supervisor criticising your dissertation draft is your anxiety based on Attitude 1: ‘Her criticism proves I’m a failure’ (‘Self-​ devaluation attitude’) or Attitude 2: ‘Her criticism does not prove I’m a failure. I’m fallible whether or not she criticises my work’ (‘USA attitude’)? Step 4: Fran selected attitude 1. If she was unsure, I would have helped her to understand this connection. Step 5: Once Fran was clear that her anxiety was based on her self-​devaluation attitude, I made and emphasised the self-​devaluation attitude-​disturbed ‘C’ connection. Then I asked: Now let’s suppose instead that you had a strong conviction in Attitude 2, how would you feel about your supervisor criticising your dissertation draft if you strongly believed that you were fallible and not a failure? Step 6: If necessary, I would have helped Fran to understand that this attitude would help him to achieve her goal of feeling concerned, but not anxious about the adversity. At this step, I made and emphasised the USA attitude-​ healthy ‘C’ connection. Step 7: I then ensured that Fran clearly understood the differences between the two B-​C connections. Step 8: Next, I helped Fran to recommit to un-​anxious concern as her emotional goal in this situation and encouraged her to see that developing conviction in her USA attitude was the best way of achieving this goal.

Help the client understand the change process It is important that the client leaves the first, and perhaps only, session with a realistic view of the change process. I usually say to clients that

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Contributions from REBT to OAAT Therapy  35 meaningful change will occur towards the end of the process whereby (a) they rehearse their healthy attitude; (b) they act in ways consistent with this developing attitude; and (c) they do this regularly over time.

Help the client to develop and implement a cognitive-​behavioural  plan In ongoing REBT, the therapist and client would negotiate a homework assignment, and they would review the client’s experience the following session. The latter does not occur in OAAT Therapy, so the REBT-​ based OAAT therapist needs to help the client to initiate the change process by putting into practice what they learned and rehearsed in the session, preferably with the anticipated example of the problem. Fran decided to rehearse her healthy USA attitude, ‘I am fallible whether or not my supervisor criticises the draft of my dissertation’ both before the meeting and during the meeting. As can be seen in this chapter, REBT is both consistent with many of the good practices of SST/​OAAT Therapy and can uniquely contribute to OAAT Therapy by offering quick and powerful ways of initiating the attitude-​based change process with the context of single sessions booked one at a time.

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6  The role of context in OAAT Therapy

In Chapter  1, I  discussed two pathways that it is possible for people to take in order to receive psychological help. The National Health Service in the UK has structured its psychological services primarily according to the ‘help according to availability’ pathway. In that chapter, I discussed the case of ‘Petra’ who sought psychological help from the NHS, and we saw that it took her 14 weeks to access one-​to-​one therapy. By contrast, if she could have accessed a walk-​in therapy service based on the ‘help according to need’ principle, then she could have been seen almost immediately. In this chapter, I  will argue that ‘One-​at-​a-​Time’ Therapy services provide an opportunity for people to be seen when they need to be seen at a time when it is convenient for them. Apart from long waiting lists, the ‘help according to availability’ pathway involves the person being sent an appointment at a date and time that is convenient to the service issuing the invitation rather than to the person seeking help. This only increases the possibility that valuable services will not be used as people do not attend appointments that are inconvenient for them, or they cancel appointments at short notice. When OAAT Therapy services are offered in a walk-​in context (see below), then appointments are always attended since the person attends the clinic only when they need to do so and without an appointment. While I have mentioned OAAT Therapy within the context of walk-​ in therapy services, it may also be used in clinics offering SST/​OAAT Therapy by appointment and also in private practice. In this chapter, I will discuss all three contexts.

OAAT Therapy by walk-​in Writing about walk-​in therapy, Slive and Bobele (2018: 28) say, ‘Central to the walk-​in concept is the therapist’s firmly held belief that the walk-​in

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The role of context in OAAT Therapy  37 session may be the only session. The focus of the session, therefore, is on what the client most wants to achieve at that particular time.’ However, as we saw in Chapter 2, it is also possible for the person to need more help after the walk-​in session has ended and the client needs to know if they can seek further help and if so, how this help can be accessed. In making a case for walk-​in therapy, Slive and Bobele (2018: 37–​38) argued that walk-​in/​single-​session counseling (including OAAT Therapy):

• • •

reduces roadblocks and frustration, increases accessibility, and creates opportunities for meaningful therapeutic conversation at just the right moment reduces wait-​ lists and other inefficiencies, produces satisfied customers and leads to lasting change in presenting concerns… and that walk-​in/​single-​session services  are cost-​efficient, add to the range of options available to consumers, and reduce risks associated with overtreatment.

When the OAAT concept informs a walk-​in service, the therapist will still try to provide all the help that the client needs in that session, but if the client does need more then they are first encouraged to derive as much benefit as possible from the session that they have just had. As mentioned several times in this book, this involves the person taking what they have learned from the session, reflecting on it, digesting it, putting that learning into practice and letting time pass before deciding if they need to book another session. If so, they have a second session and go through the same reflection-​digestion-​action-​letting time pass process before deciding whether to book a third session and so forth. This then forms the template for OAAT Therapy. I added the reflection-​digestion-​action-​letting time pass process to OAAT Therapy to ensure that the person derives as much as they can from each session before booking a further session. It is possible to run an OAAT Therapy service where a client books another session as soon as they have had the previous one. However, in my view, structuring a service like this does not encourage the client to get the most from therapy and to use their strengths and resiliency factors to do so. It is a way of allowing ongoing therapy, albeit where sessions can only be booked one at a time. Service considerations A walk-​in service can be stand-​alone or stand with other services within an organisation that offers a variety of different types of help. In both

 38

38  The role of context in OAAT Therapy cases, it is vital that the service makes clear what it can offer and what it can’t offer. Making the boundaries of OAAT Therapy clear. When a walk-​in service offers OAAT Therapy it needs to make clear the following points to potential clients:

• •

•

•

Where the service is and when it is open. A person, couple or family can walk into the service and, after completing a short intake form, be seen almost immediately by a skilled therapist for a single session where the intention is for both therapist and client to address the latter’s problem to the extent that they require no further help. The client will be encouraged to take what they have learned from the session, reflect on it, digest it, act on it and allow things to settle after which they can return for an additional OAAT Therapy session. They are discouraged from walking back in until they have gone through this ‘reflect-​digest-​act-​let time pass’ process. If the walk-​in service is part of a wider organisation that offers other services, the person may be referred to one of these forms of help after the session if it is agreed that such a referral will be beneficial for the client.

Integrating the walk-​in service with other services within the host organisation. If the walk-​in service is run by an organisation that also offers other therapy services, then it is crucial for the following conditions be met if the walk-​in service is to survive and thrive in the organisation:

• • •

All workers in the organisation need to be committed to the principle of walk-​in therapy and be advocates for it both within the host organisation and outside. All therapists who work in the walk-​in service must have been adequately trained in SST/​OAAT Therapy and have ongoing supervision and continuing professional development to support and enhance their work. Therapists who primarily work in the walk-​in service should ideally also work some of the time as therapists in the organisation’s other therapy services to prevent themselves from getting stale. Also, therapists who work predominantly in an organisation’s non-​walk-​ in therapy services should, again ideally, spend some of their time working in the walk-​in service so that they can appreciate the possibilities and power of SST/​OAAT Therapy (J. Young, 2018).

 39

The role of context in OAAT Therapy  39

•

•

The walk-​in therapy service needs to be adequately administered. Records need to be kept of all sessions, and these need to be easily accessible so that the returning client who sees a different therapist knows that the new therapist has access to and has read the notes from the previous session. All staff in the service need to be involved in researching the service (see J. Young, 2018) as an expression of improving services for clients and as a way of keeping staff engaged in the service and maintaining staff morale.

OAAT Therapy by appointment OAAT Therapy can also be offered in an organisational setting where appointments to have therapy sessions are made rather than where those sessions are available immediately as in walk-​in. An example of an OAAT appointment-​based therapy service where clients can only book one session at a time is one that I helped to develop with the student counselling service of the Arts University, Bournemouth (AUB) in the UK. Previously, the university’s counselling service offered all students six sessions of counselling which could be booked in advance. This resulted in a waiting list of up to two weeks for an initial access appointment and then a further waiting list of between six and nine weeks for allocation to a counsellor for regular fixed sessions. When the AUB service modified its service provision with the express aim of reducing waiting times, it advertised itself to the university community thus ‘The AUB Counselling Service offers single therapeutic sessions for one hour booked on a session by session basis’. In its first year, at the busiest point of the student term, there was only a five-​day wait for a session. While some students would have preferred to have had the opportunity to book a series of sessions ahead of time, the majority were pleased to have the opportunity to book an appointment to see a counsellor close to the point of need and at a time that suited them. What came as a surprise to the counsellors at AUB was the number of students who booked to see a different counsellor if they needed further help after the first session. While, of course, some students did so because they did not connect with or find their first counsellor helpful, the majority indicated that they were happy to get different perspectives from different therapists. This echoes the views from clients of family-​ based SST services where a therapist is supported by an observing team, and where different people in the team voice their opinions when the team gives feedback to the client concerning what the client might find

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40  The role of context in OAAT Therapy useful based on what they have discussed so far with the ‘treating’ therapist (see Hoyt et al., 2018). What the service did find was that in the first 12 weeks of operation, some students just had one session; most students had 2–​5 sessions spread out over the term. Some students booked in regularly and usually on a weekly basis with the same counsellor but notably at different times based on their convenience. Remarkably, these student clients reported having actually benefitted under the new model being able to have more sessions than under the old six-​ session model and without disadvantaging other student clients. (personal communication) Change in advertised focus At the time of writing,1 the AUB counselling service is considering a number of changes to the way it advertises itself in order to portray the potency of the OAAT service model. The university as a whole has been keen to emphasise a student-​focused approach to all of its Student Services. However, after a full academic year of operation, it was noted that some students still continued to book weekly counselling sessions. Reasons for this could include a sense of entitlement because of higher university fees, or referrals back to the AUB counselling service from overstretched services like the NHS. It was also apparent that some students were accessing the service having previously had many years of weekly counselling through school or college, so this set their expectation for counselling at university. All AUB counsellors were keen to embrace and work with the OAAT structure. Moving forward, a stronger emphasis on ‘student empowerment’ rather than on ‘student focus’ could further challenge the view that counselling has to be weekly. It would ensure that the counsellor has an opportunity to initiate a conversation on the reflect-​digest-​act-​let time pass process that is at the heart of OAAT Therapy and places the decision on the frequency of sessions with the student–​counsellor dyad than on the student alone. In order to facilitate this conversation, the service made the following changes to its advertising. Talking to a counsellor in a safe, non-​judgemental and confidential setting can enable you to work through your problems with the aim of reaching a solution. Counselling is also an excellent tool for your own personal development.

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The role of context in OAAT Therapy  41 was replaced with Talking to a counsellor in a safe, non-​judgemental and confidential setting can enable you to draw on your existing strengths and resiliency factors to work through your problems with the aim of reaching a solution. Counselling is also an excellent tool for your own personal development. In my view, the service could stress more the principle that ‘the student and counsellor will decide together what is best for the student’ rather than the principle that the service is ‘student-​focused’, but it has yet to do so. Flexibility in OAAT I have argued that in order to get the most from the OAAT Therapy service model, AUB counsellors would need to stress more that counselling is a fusion of what both student and counsellor bring to the process and that decisions about frequency of sessions (if more are required) should ideally be taken jointly by counsellor and student. I  question the practice where a student leaves a counselling session and books another one immediately for the following week without having had the opportunity to engage in the ‘reflect-​digest-​act-​let time pass’ process; this is a particular risk if appointment booking is undertaken by reception staff and is outside of the counsellor’s control. I have argued that where the student is capable of engaging with this process by applying their strengths and resiliency factors to what they have learned from the counselling session that they have just had, the counsellor should initiate a conversation with them about doing so. Having said this, there are, of course, student clients who need to be seen the following week and it is therapeutic for them to book this session at the end of their previous one. Students in need should not be refused quick access to another session until they have engaged in the ‘reflect-​digest-​act-​let time pass’ process. What I am advocating is that this process should be introduced and discussed with students who can benefit from it and not imposed on all students. The OAAT Therapy service model is ultimately a flexible one. The structure of an OAAT Therapy session at AUB What follows is the session structure employed by counsellors at AUB in their new OAAT-​based counselling service. It should be stressed at

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42  The role of context in OAAT Therapy the outset that AUB counsellors use the following as a guide and not as a straitjacket and they bring their own therapeutic orientation to the work. OAAT is not an approach to therapy itself, but rather a mode of service provision which can be delivered in a variety of ways. Setting the scene. Here, the counsellor explains the service and the amount of time they and the client will spend together. In addition, the counsellor explains the service’s confidentiality policy and refers the client to the service’s policy statement online or to the service’s booklet if the student requires more detailed information. Creating a focus. Here, the counsellor asks the client what is the single most important concern that they have right now. They then proceed to explore the most relevant type of help needed. In doing so, the counsellor helps the client to prioritise needs and helps keep the client’s most immediate and critical needs a priority while being mindful of their other needs. Assessing risk. As soon as is practicable, the counsellor assesses the client’s immediate risk of suicide/​self-​harm or harm to others. If the risk is high, then the counsellor discusses plans to keep the client and/​ or others safe. Assessing previous attempts to solve the problem. As people usually try to resolve a problem themselves, it is vital that the counsellor discovers what things the client has tried before coming for counselling. The role of the counsellor is to encourage the use of strategies that have been helpful and discourage the use of those that have proven unhelpful. Identifying strengths and resiliency factors. Here, the counsellor asks the client about their strengths and resiliency factors that they can draw on throughout the counselling process both within and outside sessions to facilitate change. For example, the counsellor might ask, ‘What inner strengths and resiliency factors do you have that it would it be useful for us to know about that might help you deal with the problem?’ If necessary, the counsellor educates the client about key strengths and resiliency factors, such as positive outlook, spiritual convictions, sense of hope, feelings of personal control, creativity persistence and humour. The counsellor also explains the role of these factors as crucial components of the process of moving forward. Identifying external resources. Here, the counsellor seeks to discover resources in the client’s environment that they can make use of to help solve their problem; for example, healthy family relationships and friendships and useful organisations that can help support the client after the session. Identifying the green shoots of change and growing these shoots. Here the counsellor encourages the client to identify the smallest change needed

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The role of context in OAAT Therapy  43 to show them that things are heading in the right direction. Once this has been determined, the counsellor helps the person to plan to bring about this change as soon after the session as possible and to practise the solution in the session first, if practicable. Linking to resources in the ‘counselling booklet’ as appropriate. As the end of the session approaches, the counsellor refers, if appropriate, to any information, links, apps, etc. that the client might find useful after the session has finished. Ending the session well. It is important for the counsellor to bring the session to a satisfactory conclusion. This involves asking the client if they have any questions to ask before closing and asking any that they do have. A good question in this context is, ‘What question(s) will you wish you had asked me when you get home today?’ Making reference to the availability of further help. The way in which the counselling service at the Arts University Bournemouth is structured is that further sessions can be booked, but only one at a time. Counsellors should encourage the client to go away first to reflect on what they have learned from the session, digest this learning, act on it and let time pass to see what happens before considering whether or not to seek further help. However, at present, it is possible for the client to have ongoing therapy by booking another session at the end of the one just completed. Where student clients and counsellors have long experience of regular weekly therapy, there is a risk that both client and therapist revert to this pattern of interaction, highlighting the need for ongoing training and supervision for counsellors new to this approach. In my view, while innovative, the OAAT-​based AUB counselling service could increase the potency of the OAAT Therapy service provision by further stressing the ‘reflect-​digest-​act-​let time pass’ process that encourages the client to derive maximum benefit from the session and their own strengths and resiliency factors in taking matters forward.

OAAT in private practice If a therapist is in private practice, there is, from an economic point of view, the ever-​present motivation to encourage a person to enter ongoing therapy that provides a steady, regular income, rather than to encourage them to have a session and to return only when they are sure that they need additional help. Talmon (1990) recognised this and suggested that the therapist might consider charging a higher fee for OAAT Therapy. However, an alternative view is that if a therapist offers OAAT Therapy and gets known for this, then they will get more than enough referrals and self-​referrals so that they do not have charge more

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44  The role of context in OAAT Therapy for OAAT Therapy than for ongoing sessions. I appreciate that this is a risk for private practitioners, but nothing ventured, nothing gained. Jeff Young (2018) argued that it is crucial to embed SST/​OAAT Therapy into the other services offered by an organisation. At the Bouverie Centre, which he directs in Victoria, Australia, clients begin with a single session, and if that is all they need then therapy stops there, but they need further help they get referred to one of the centre’s other services. In my own private practice, SST/​OAAT stands alongside the other services that I offer. When a person contacts me, I endeavour to speak to them on the telephone as quickly as possible where I outline these services, explain a little about them and answer any questions before deciding with the person which service is most suitable for them. Then I explain that I offer ongoing individual therapy, couple therapy, coaching and two forms of very brief therapy: Single-​Session Integrated Cognitive Behaviour Therapy (SSI-​CBT) and One-​at-​a-​Time (OAAT) Therapy, the latter being a new development. The differences between the two are as follows. SSI-​CBT involves a 30-​minute pre-​session telephone contact, a face-​to-​face session lasting up to 50 minutes carried out shortly after the telephone contact and a 30-​ minute follow-​ up session conducted three months later (Dryden, 2017). OAAT Therapy involves a face-​to-​face session lasting up to 50 minutes followed a period where the client reflects on what they have learned in the session, digests it, acts on it and then lets time pass before deciding whether or not to have another session. As stressed throughout this book, the person can only book one session at a time. If a person nominates OAAT Therapy and it turns out that one of the other services that I offer is more suitable, then the person can easily transfer to that service. In the following chapter, I  discuss my REBT-​based approach to OAAT Therapy and illustrate it in the final chapter.

Note 1 August 2018.

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7  REBT-​based OAAT Therapy

In Chapter 4, I detailed what a variety of authorities deem to be good practice in SST/​OAAT Therapy (e.g., Talmon, 1990; Slive & Bobele, 2011; Hoyt & Talmon, 2014; Hoyt et  al., 2018; and summarised in Dryden, 2019a). In doing so, I  briefly outlined REBT’s position on each of the presented points of good practice. In Chapter 5, I brought REBT centre stage and considered what it offers the practice of OAAT Therapy. In this chapter, I  go further and focus on what an REBT-​ based OAAT Therapy might look like as seen through the lens of one practitioner –​  me.

‘Swiping right’ People who use the dating app Tinder know that ‘swiping right’ on a photo of someone means that they would consider meeting the person in real life to see if there is real chemistry between them. ‘Swiping right’ in therapy means, in the present context, that someone has learned of OAAT Therapy and thinks that it may be useful for them and either wishes to opt for this approach or wishes to explore it further. This happens a lot in my own practice. When I  outline my range of services (see Chapter 6), usually over the phone, and a person expresses an interest in OAAT Therapy, I say the following: ‘One-​at-​a-​Time’ Therapy involves us working together in the first instance for one session to see if I can help you take a significant step forward in solving your problem. By the end of the session, I will help you to formulate a plan, reflect on it, digest it, put it into practice and let time pass. Then, if you need it, we can have another session.

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46  REBT-​based OAAT Therapy

Suggest pre-​session preparation If the person wants to proceed, I ask them to prepare for the session so that they can get the most out of it. I suggest that they do so in their own way, but if they ask for an idea, I recommend one or more of the following:

• • • • • •

Specify the main problem you want to address in OAAT Therapy. Specify what you realistically want to achieve from OAAT Therapy. List your strengths and resiliency factors that will help you get the most from OAAT Therapy. List the values that underpin what you want to achieve from therapy. List the attempts that you have already made to solve your problem, and what the outcome of each was. Detail the resources in your environment can you use to help you address your problem.

Clarify parameters of OAAT Therapy At the beginning of the session, I make sure that the client understands and agrees with the parameters of OAAT Therapy. As previously mentioned, these are that we have agreed to meet for a session with the intention of dealing with the person’s problem in that session. By the end of the session, I would have helped the client to develop a plan to address their problem. They agree to reflect on and digest what they have learned from the session, implement the plan and then let time pass before deciding whether or not they need another session. I  ask my client to give their informed consent to OAAT Therapy, which I document in my notes. Others therapists prefer to get such informed consent in writing.

Initiate goal orientation Initially, I tend to ask my client what they would like to achieve by the end of the session. My experience is that when I ask for a goal at the very outset, the client gives me a vague goal which may be the presence of a positive state (e.g., ‘I want to be happier’), a coping goal (e.g., ‘I want to cope with stress better’) or the absence of a negative state (‘I don’t want to be anxious’). In Chapter 4, I detailed what de Shazer (1991) said about workable goals in brief therapy (see p. 21). In addition to these features, I am also guided by the ‘SMART’ acronym when it comes to working with such vague goal statements. Thus, I help my client to set goals that are specific (‘S’), meaningful (‘M’). achievable (‘A’), realistic (‘R’) and time-​bound (‘T’).

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REBT-​based OAAT Therapy  47

Identify strengths, resiliency factors and values If I have not asked the client to prepare for the session by listing their strengths, resiliency factors and/​ or values, I  will use an opportune moment during the session to do so. This can be at any point during the session.

Identify external resources Again, if I have not asked the client to prepare for the session by listing their potentially helpful external resources, I  will use an opportune moment during the session to do so. Again, this can be at any point during the session. In particular, I  will ask the person to nominate people who can be supportive of their efforts to change.

Create a focus In my view, the power of OAAT Therapy lies in my client and myself creating and working with a focus. In REBT, this is usually expressed as a problem with an idea of what the client has in mind as an acceptable and realistic goal. A good focus is one that is specific enough to encapsulate the client’s nominated problem and is agreed to by the client and myself. OAAT means in this context ‘one issue at a time’. If the client wanders away from this focus either by introducing another topic or by becoming very general in their discourse, then it is my job to bring them back to the focus and encourage them to be sufficiently specific so that we can effectively address their problem. If possible, I ask the client for a specific example of their problem and preferably one that is likely to be imminent. I have found that working with an imminent example of the problem helps the client and me to formulate a joint plan to address this problem after the session is over. If I have to, I will interrupt the client to bring them back to the agreed focus. In my experience, it is best to ask a client for permission to interrupt them before doing so. In addition, I  check periodically during the session to ensure that we are still discussing the most critical issue with which the person wants help.

Carry out an adversity-​based assessment Once the client and I have arrived at a good enough focus, then I will undertake an REBT-​based assessment of the problem that will also take into account how the client sees the problem. Before doing so, I have

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48  REBT-​based OAAT Therapy found it helpful to ask my client if they would be interested in how I understand the problem. Their assent increases their attention to my assessment. Using the Situational AC part of the ABC framework When I  use the ‘Situational AC’ part of the ABC framework to help myself and the client to understand their problem, I prefer to use a specific example of the problem and one that is imminent (as explained above).1 A specific example helps the client to become and stay emotionally engaged in the assessment process, whereas a general discussion of the problem will not achieve such emotional engagement. Get a description of the situation. It is useful to get a description of the situation in which the problem occurred. I  try to discover where the problem occurred and who was present and what they were doing that was problem-​relevant. Identify the problem ‘C’. REBT theory argues that when faced with a negative event2 at ‘A’, a person will experience a negative emotion at C.  That negative emotion will either be (a)  healthy in that it will encourage the person to face the adversity, process it and deal with it constructively or (b) unhealthy in that it will discourage the person to face the adversity and this avoidance will lead to the person developing a set of unconstructive responses to the adversity. The latter leads them to seek help. My task at this point is to help my client to identify their main unhealthy negative emotion (UNE) and their major unconstructive behavioural and cognitive responses that accompany this UNE (see Dryden, 2012). Identify the adversity at ‘A’. In my view, perhaps my most important task is to help the client to identify what they were most disturbed about in the problem-​based situation that we are discussing. I have outlined a time-​efficient way of doing this that I  have called Windy’s Magic Question.3 Basically, the UNE gives a clue to the adversity’s theme, and the specific ‘A’ is the embodiment of this theme in the problem example being assessed. Thus, if ‘C’ is anxiety, then the basic adversity theme in anxiety is ‘threat’. So what I am looking for is what the client found most threatening in the problem situation, and this is ‘A’. Encourage the client to assume that ‘A’ is correct temporarily. I resist the temptation to help the client question the accuracy of ‘A’, particularly if it is clear that it is distorted (as it often is). Instead, I encourage them to assume temporarily that their identified ‘A’ is correct. I  do this to help us to identify their rigid/​extreme attitudes at ‘B’ which according

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REBT-​based OAAT Therapy  49 to REBT theory is at the heart of their problem (see Chapter 2). Thus, in the example of the work I did with Fran (see Table 5.1), I encouraged her to assume temporarily that her supervisor would criticise the draft of her dissertation rather than question her on the likelihood that her supervisor would be critical. I then asked her to focus on this ‘A’ while staying in touch with her anxiety to enable us to identify the rigid/​ extreme attitudes that underpinned these feelings.

Set an adversity-​based goal Before I move to focus on the client’s basic attitudes at ‘B’ in the ABC framework, I  find it useful to consider what the client’s goal is with respect to the adversity at ‘A’. Adversity-​based goal-​setting at this stage of the process is different from initiating a goal orientation at the beginning of the session, which I discussed earlier in this chapter (see p. 46). With respect to the latter, the client is asked for a general goal orientation that is not informed by the adversity-​based assessment that comes later in the process. With respect to the former, we now know more about the client’s problem. We know what adversity features in their problem and we know what their disturbed (emotional, behavioural and cognitive) responses are to this adversity. When I  help my client set an adversity-​based goal, I  have two primary tasks. First, I  need to help them see that if they try to bypass the adversity and move towards their initially conceived goal, then they will usually fail. Their problem is their failure to deal with the adversity in question, and therefore they need to face it and deal with it rather than bypass it. Thus, I need to help Fran see that for her to be stress-​ free in her studies (her initially stated goal), she first needs to set a goal in respect to her supervisor’s criticism of her dissertation draft that is healthier than anxiety. Second, as the adversity is negative, I need to help the client to see that it is healthy for them to feel bad about the adversity. This is where REBT’s distinction between an unhealthy negative emotion (UNE) and a healthy negative emotion (HNE) is so important.4 UNEs stem from a person’s rigid/​extreme attitudes towards adversities, while HNEs stem from flexible/​non-​attitudes towards the same adversities. Thus, it is healthy for Fran to feel concerned (HNE) rather than anxious (UNE) about having her dissertation draft criticised by her supervisor in that, although this concern is negative (in feeling tone), it is accompanied by constructive behavioural and cognitive responses (see Table  5.1). Anxiety, on the other hand, is accompanied by unconstructive behavioural and cognitive responses (see Table 5.1).

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50  REBT-​based OAAT Therapy Even though time is at a premium in OAAT Therapy, I find that it pays off to spend time on this issue to the point when the client can commit themselves to pursue their adversity-​related goal.

Focus on basic attitudes and choice My practice in applying REBT to OAAT Therapy is to focus on basic attitudes5 at ‘B’ once I have helped the client to identify the ‘AC’ components of their problem and set their adversity-​related goal. Identify ‘B’ Focusing on ‘B’ at this point in the process allows me to help my client to identify at the same time the rigid/​extreme attitude that underpins their disturbed emotional, behavioural and cognitive responses to the adversity (at ‘A’) and the flexible/​non-​extreme attitudes that underpin their alternative healthy/​constructive emotional, behavioural and cognitive responses to the same ‘A’. While there are a number of doing this, perhaps the most time-​efficient is a technique that I  created entitled Windy’s Review Assessment Procedure (WRAP).6 Underscore attitudinal choice While helping the client to identify their rigid/​extreme and flexible/​non-​ extreme attitudes, I  stress the fact that they have a choice concerning which attitude to hold going forward. If they choose the flexible-​non-​ extreme attitudes, I point out that (a) they need to act on and practise these attitudes if they are going to have an impact on their responses, and (b) these attitudes may not ‘feel right’ for a while until they have been integrated into the person’s attitudinal system. Initiating attitude change Once the client has nominated the flexible/​non-​extreme attitude, I ask a number of questions to help underpin their choice. In traditional REBT this is known as ‘disputing beliefs’. What I do is to take both attitudes together and ask the client three questions: (a) which is true and which is false? (b) which is logical and which is illogical? (c) which will yield the best and the worst results? I ask for them to explain their answers. The aim is for the client to understand that their rigid/​extreme attitudes are false, illogical and largely unconstructive and that their flexible/​non-​ extreme attitudes are valid, logical and mostly unconstructive.

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REBT-​based OAAT Therapy  51 Next, I ask the client to commit to strengthening their flexible/​non-​ extreme attitude towards the adversity that features in their problem. At this point, I  also enquire whether or not they have any doubts, reservations or objections (DROs) to doing this, and if they do then I help them to examine and hopefully relinquish these DROs. At the end of this process, the client should ideally see which attitude they need to adopt in order to solve their problem.

Encourage in-​session practice of the solution If possible, I encourage my client to engage in-​session practice of the solution to their problem. This often takes the form of:

• • •

a dialogue between the part of themselves that holds the rigid/​ extreme attitude and the part of themself that holds the flexible/​ non-​extreme attitude; an imagery exercise designed to help the client to rehearse their flexible/​non-​extreme attitude;  or behaviour change based on holding their flexible/​ non-​ extreme attitude.

If I  can help my client to engage their healthy negative emotions during this process, then so much the better since doing so increases the impact of in-​session solution practice. Such practice enables the client to get a ‘feel’ for the solution and also to make adjustments to it where needed.

Help the client to develop a plan Ongoing REBT is marked by the negotiation of weekly homework tasks designed to help the person implement learning in a stepwise fashion. These tasks tend to be specific and directly related to the content of each therapy session. In OAAT Therapy a different focus is required. What I do is to help my client to develop a general plan which involves taking the flexible/​non-​extreme attitude they have chosen to adopt and selecting adversity-​related contexts in which they can practise it. Then they should develop behaviours and ways of thinking that support the flexible/​non-​extreme attitude and plan to carry them out while facing the adversity. Another way of approaching the issue of a plan is this. I  ask the client for one thing that could take away from the session which, if they implemented it, would make a significant difference to their life (Keller

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52  REBT-​based OAAT Therapy & Papasan, 2012). After doing so, I help them to develop a plan to put this learning into practice When discussing the implementation of the plan, I  encourage my client to implement the ‘challenging, but not overwhelming’ principle (Dryden, 1985)  where relevant. This states that the person should face adversities that are challenging for them at the time, but are not overwhelming, and to do so with regularity. I also find it particularly helpful to remind my client that they have internal strengths, resiliency factors, values and external resources upon which they can call in order to initiate and maintain their plan (see also the section on ‘Explain and encourage the implementation of the “reflect-​digest-​act-​let time pass” process’ below). It is important to introduce a note of realism at this point, and I  do so by asking the client to identify potential obstacles to them carrying out their plan and to brainstorm ways of dealing effectively with them. Given the vagaries of the human memory, I suggest that the client make a written note of the salient features of their plan and to do so as specifically as possible using encouraging rather than discouraging language. Such salient features include:

• • • • •

the flexible/​non-​extreme attitude that the client wishes to develop; the behaviours and ways of thinking that will support the development of this attitude; the adversities the person needs to face while practising their healthy attitude and associated behaviours and ways of thinking; a practice timetable; a list of obstacles to implementing the plan and how these can be dealt with effectively.

Encourage the client to summarise When I sense that we are entering the concluding part of the session, I invite the client to summarise the work that we have done so far. It is vital that they summarise the session rather than me doing it since it encourages the client to take an active role in the session even as it closes. Also, it is a way of me checking what the person takes away with them from the session and provides me with the opportunity of adding to their summary or modifying it if appropriate. Ideally, there should be a close approximation between the features of the client’s plan (see above) and the client’s summary.

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REBT-​based OAAT Therapy  53

Explain and encourage the implementation of the ‘reflect-​ digest-​act-​let time pass’ process I have mentioned a number of times in this book that it is crucial for the therapist to explain at the outset that the goal of OAAT Therapy is to see if by working together the client can be helped with their problem in one session. If not, then the client can have access to further help, one session at a time. What they cannot do in OAAT Therapy is to book for more than one session going forward. If they need ongoing therapy, for example, then they should be encouraged to find it, or if the organisation in which they have been seen has an ongoing therapy service, then they should be transferred to it and join whatever waiting list (if any) this service has. The ‘reflect-​digest-​act-​let time pass’ process Quite often when the client has opted for an OAAT Therapy session in the full knowledge of what this means, it may not be clear at the end of a session if the client needs another session of therapy. When this is the case then I encourage them to engage in a process that I have termed ‘reflect-​digest-​act-​let time pass’. This involves them taking away from the session what they have learned from it, reflecting and digesting on this learning and then implementing the plan that they co-​created with me. Then, having given this part of the process time to settle down or ‘mature’, they should be clear if they need further help. If they do, then they should know how to access this help, which will usually be an additional session. They access this additional session, and once they have had it, they again engage in the ‘reflect-​digest-​act-​let time pass’ process before again deciding whether or not to seek another (third) session. OAAT Therapy is particularly suited for situations where the client’s problem can be dealt with fairly quickly, but access is still available much later if they experience and want help with a very different problem. The use and misuse of OAAT Therapy It is possible for a client to use an OAAT Therapy service to get ongoing therapy by booking another session at the conclusion of the session that they just had. When a client does this, two things may be happening. First, the client may need ongoing therapy, which should be acknowledged and arranged. If this is not possible, then the client and therapist should explicitly conclude together that it is acceptable for the

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54  REBT-​based OAAT Therapy client to use the OAAT Therapy service in this way. Second, the client may not need ongoing therapy, but think that they do. When the client may think that they need ongoing therapy, but their therapist does not agree, ideally they should have an open conversation about the reasons for their differing conclusions. If possible, the client should be encouraged to reflect on the strengths, resiliency factors, values and external resources they nominated earlier in the session to think about what might happen if they used such internal and external factors in the independent pursuit of their goal. When I encounter this, I encourage the client to conduct an experiment whereby they use these factors for an agreed time period while implementing the reflect-​digest-​ act-​let time pass process and if they conclude at the end of that agreed period that they need a further session then they can have one. As mentioned in Chapter 6, the OAAT Therapy way of working is flexible. It should neither be imposed on people who would not benefit from it nor should it be withheld from people who may find it useful.

Deal with last-​minute issues and end well As with other forms of SST, it is important for the OAAT Therapy session to come to a satisfactory conclusion where there are no loose ends in the client’s mind. To this end, I encourage the client to raise any last-​minute issues or concerns and deal with them effectively so that the client can go away fully focused on taking their learning forwards and keen to begin to implement their plan. A good question in this respect is this: ‘If when you get home today, you wished you had asked me something or told me something, what would that be?’ In the final chapter, I discuss a case of REBT-​based OAAT Therapy so that you can see how the above points can be implemented in practice.

Notes 1 See Table 5.1 for an example. 2 Referred to as an ‘adversity’ in this book. 3 See Table 5.2 for an example. 4 See Chapter 2. 5 The term ‘basic attitude’ allows the letter ‘B’ to be retained in the ABC framework. In this section, however, I will use the term ‘attitude’ throughout. 6 See Table 5.3.

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8  REBT-​based OAAT Therapy in action

In this chapter, I review the work that I did with ‘Sam’,1 a 32-​year-​old solicitor who sought therapy because his ‘work–​life’ balance was not right and while he was doing well at work, his girlfriend was threatening to end their relationship because she rarely saw him and when she did he was always checking his phone.

‘Swiping right’ Sam contacted me because he had heard of my work in Single-​Session Therapy and ‘liked the idea of it’. He said that he did not want to spend a long time in therapy and was keen to take what he could from it and ‘work with it myself’. It turned out that he preferred my OAAT Therapy service rather than my SSI-​CBT service (see Chapter 6) and we agreed to move forward on that basis.

Suggest pre-​session preparation I asked Sam if he wanted to do some preparation for the session and he agreed. We concurred that he would come to the session with an explicit statement of his problem, a clear idea of his goal and a list of his internal strengths, resiliency factors and values that could help him get the most from OAAT Therapy.

Clarify parameters of OAAT Therapy At the beginning of the session, I  outlined with Sam the nature of OAAT Therapy. I stressed that we would work together in the session to develop a plan that Sam could implement to achieve his goal, and after the session he would reflect and digest what he learned from the session,

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56  REBT-​based OAAT Therapy in action put his plan into practice and let time pass before deciding whether or not he wanted to book another session. Sam gave his informed consent to proceed on this basis.

Initiate goal orientation Initially, when asked what he wanted to get out of the session, Sam said he wanted to get a better ‘work–​life’ balance. I asked him what would be different when he achieved such balance, to which he replied, ‘I would be work when at work and give my full attention to other things when I was not at work’.

Identify strengths, resiliency factors and values Sam said that the strength that would be most helpful in therapy was his determination. Once he decided on a course of action, he would use his determination to keep to it. He also said that he valued family and friends, but was aware that he had long neglected them.

Identify external resources Sam suggested that his girlfriend was the person most likely to support him in therapy as she was the one who suggested that he seek help in the first place.

Create a focus Sam said that he was able to be at work when he was at work. His problem that was not able to concentrate fully on his girlfriend, for example, when he was with her. He agreed that this was a good example of his problem. The issue was he kept checking his work emails on his phone. When I asked why he had his phone on while he wanted to concentrate fully on his girlfriend, Sam replied that he would be anxious and restless if he didn’t.

Carry out an ABC assessment of the problem and possible solution In response to my question, Sam said that he was interested in using the ABC framework that informs my view of such problems. We did so and eventually arrived at the following assessment of his problem and potential solution (see Table 8.1)

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REBT-​based OAAT Therapy in action  57 Table 8.1 ABC Assessment of Sam’s problem and potential solution Situation Have turned off phone when I am with girlfriend so I cannot check work emails Adversity (‘A’) I won’t be on top of my work Basic Attitudes (‘B’) (Rigid and extreme)

Basic Attitudes (‘B’) (Flexible and non-​extreme)

I must be on top of my workload

I want to be on top of my workload, but I don’t have to be

If I am not, then it will be terrible

If I am not, then that would be unfortunate, but not terrible These serve as Sam’s potential solution

Consequences (‘C’) (Unhealthy and dysfunctional)

Consequences (‘C’) (Healthy and functional)

Emotional = Anxiety

Emotional = Concern

Behavioural = Turning on phone and checking work emails

Behavioural = Focus on girlfriend and not turning on phone to check work emails

Cognitive = ‘If I am on top of my workload, I will be completely out of control at work’

Cognitive = ‘If I am not on top of my workload, I am still much more in control than out of control’ These serve as potential adversity-​ related goals for Sam

During that assessment, I  encouraged Sam to assume temporarily that he was not on top of his workload and to develop healthy responses to that adversity characterised by concern, refraining from checking his work emails and a realistic assessment of his level of self-​control. We also discussed the advantages of this adversity-​related goal. Sam stated that it would definitely help him to develop a better work–​life balance and improve his relationship with his girlfriend. On the downside, he thought it might tarnish his reputation at work as being the person in

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58  REBT-​based OAAT Therapy in action the office who responds first to work emails. Sam considered that if this happened, this reputational loss was worth the gains he would achieve if he achieved his adversity-​related goal.

Focus on basic attitudes and choice When I helped Sam to stand back and consider both the rigid/​extreme attitude and his flexible/​non-​extreme attitude (see Table 8.1), he clearly favoured the latter over the former. He also acknowledged that he could not engage with his girlfriend fully and stay on top of his workload and that something had to give. At present, he saw that his relationship with his girlfriend and other aspects of his non-​work life were suffering, and he was not happy with that. ‘If I am not going to be on top of my workload [at present defined by Sam as responding immediately to every work email], then the worst that will realistically happen is that some of my clients might complain.’ But as I helped Sam to see, if they did complain it would be because he had trained them to expect an immediate response and he was now retraining them to expect a less responsive, albeit still professional service.

Encourage in-​session practice of the solution In order to have Sam practise his new flexible/​non-​extreme attitude towards not being on top of his work (see Table 8.1), I asked him to put his phone on and wait for the ‘ping’ that indicated that a work email had just come in. This happened almost immediately. Sam mentioned that he felt an immediate urge to check his phone which I normalised but encouraged him to stand back, accept the discomfort of not responding and practise his new flexible/​non-​extreme attitude. He had to do this several times as his phone pinged several times, however at the end of the in-​session practice he felt more in control of himself even though he was not responding immediately to the emails. I reminded Sam that he could use his nominated strength of determination to help him with this going forward.

Help the client to develop a plan Sam and I developed a plan that had the following components:

•

He would focus on work between the hours of 8 a.m. and 6.30 p.m. which were his contracted work hours. The exceptions to this rule

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REBT-​based OAAT Therapy in action  59

•

• •

would be when he had to take part in Skype conferences with clients from abroad. These happened approximately twice a week. When out with his girlfriend he would not have his phone on at all. While this would not expose him to his adversity at ‘A’  –​that he was not on top of things at work, it would be in the service of his relationship in that his girlfriend objected to Sam having his phone on at all. At other times and with other people he would have his phone on, except when it would be disruptive to do so, but would not respond to work emails and work calls. We agreed that this would expose him to his ‘A’ and enable him to practise his solution. Sam agreed that he would check his work emails twice a day when he was not at work, but that he would not respond to them. Again, this would afford him an opportunity to practise his solution in the face of his adversity. Sam agreed to remind himself of the following variables at least once a day and when he was struggling to practise his solution: – His overall goal was developing a greater work–​life balance. – He was determined to solve the problem. – One of his values was ‘spending quality time with friends and family’, which he had hitherto neglected.

I encouraged Sam to make a written copy of the document, which we both signed. As a lawyer, Sam liked the idea of this forming a contract between us.

Encourage the client to summarise Sam summarised what we covered in the session and particularly the point that he needed to develop a flexible attitude if he wanted a better work–​life balance.

Explain and encourage the implementation of the ‘reflect-​digest-​act-​let time pass’ process I reminded Sam of the ‘reflect-​digest-​act-​let time pass’ process, and he agreed to engage with this process. I further reminded him that he had a written note of the ‘helpful’ variables on his plan to which he could refer if the ‘going got tough’ for him. I also asked him to identify any vulnerability factors, i.e., situations that if encountered might prove difficult for him to deal with. He mentioned being asked to help a colleague with a case outside working hours. He said that he would feel guilty if he said

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60  REBT-​based OAAT Therapy in action no and that might lead him to do work outside his agreed plan. I first helped Sam to realise that while it was bad to let a colleague down, that he was not a bad person for doing so. Rather, he was an ordinary fallible human being struggling to put himself first. I also reminded him that it was bad to let himself down and that in life someone has to be let down in such circumstances. He agreed that if he did not look after himself, nobody would. We then very briefly rehearsed him saying no to his colleague, which he found easier than he thought.

Deal with last-​minute issues and end well Sam did not have any last-​minute issues. He agreed to contact me gain if he needed another session and in three months if not to tell me how he was progressing.

Follow-​up Sam emailed me about three months after our session. He said that he did not need to have another session and that while not being fully on top of his work, he was relatively on top of his work and that was good enough for him. He was also delighted to tell me that he and his girlfriend were getting on much better and that they had just gotten engaged. Sam also wrote that his boss had noticed a change in his work practice, but supported him in this change. One of his clients had complained about Sam’s ‘lack of responsiveness’, but his boss dismissed this complaint as unreasonable. Both realised that Sam had previously created the expectation in the client’s mind that he would respond immediately and when he stopped doing so, the client, perhaps understandably ‘felt short-​changed’. Sam concluded that he hoped that he would not have to consult me again, but that he would do so about the same issue or a different one if necessary. He ended by saying that he was pleasantly surprised with his ability to deal with his problem in one session and said that he would be happy to help spread the word about OAAT Therapy. Because of this last point, I asked for Sam’s permission to use his ‘case’ in this book, which he readily gave. All identifying features have been changed, and ‘Sam’ (not his real name) has read and approved the material in this final chapter.

Note 1 Not his real name.

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References

Appelbaum, S.A. (1975). Parkinson’s Law in psychotherapy. International Journal of Psychoanalytic Psychotherapy, 4, 426–​436. Battino, R. (2014). Expectation:  The essence of very brief therapy. In M.F. Hoyt & M. Talmon (Eds.), Capturing the Moment: Single Session Therapy and Walk-​In Services (pp. 393–​406). Bethel, CT: Crown House Publishing. Bernard, M.E. (2018). Rationality in coaching. In M.E. Bernard & O.A. David (Eds.), Coaching for Living: Theory, Techniques and Applications (pp. 51–​66). New York: Springer. Colman, A. (2015). Oxford Dictionary of Psychology, Fourth Edition. Oxford: Oxford University Press. Cummings, N. A. (1990). Brief intermittent psychotherapy through the life cycle. In J.K. Zeig & S.G Gilligan (Eds.), Brief Therapy: Myths, Methods and Metaphors (pp. 169–​194). New York: Brunner/​Mazel. de Shazer, S. (1991). Putting Difference to Work. New York: Norton. Dryden, W. (1985). Challenging but not overwhelming: A compromise in negotiating homework assignments. British Journal of Cognitive Psychotherapy, 3(1),  77–​80. Dryden, W. (1986). Vivid methods in rational-​emotive therapy. In A. Ellis & R.  Grieger (Eds.), Handbook of Rational-​Emotive Therapy, Volume 2 (pp. 221–​245). New York: Springer. Dryden, W. (2001). Reason to Change: A Rational Emotive Behaviour Therapy (REBT) Workbook. Hove, East Sussex: Brunner-Routledge. Dryden, W. (2012). Dealing with Emotional Problems Using Rational-​Emotive Cognitive Behaviour Therapy:  A Practitioner’s Guide. Hove, East Sussex: Routledge. Dryden, W. (2013). The ABCs of REBT:  Perspectives on Conceptualization. New York: Springer. Dryden, W. (2015). Rational Emotive Behaviour Therapy: Distinctive Features, Second Edition. Hove, East Sussex: Routledge. Dryden, W. (2016a). Attitudes in Rational Emotive Behaviour Therapy: Components, Characteristics and Adversity-​Related Consequences. London: Rationality Publications.

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62  References Dryden, W. (2016b). When Time Is At a Premium:  Cognitive-​ Behavioural Approaches to Single-​Session Therapy and Very Brief Coaching. London: Rationality Publications. Dryden, W. (2017). Single-​Session Integrated CBT (SSI-​CBT): Distinctive Features. Abington, Oxon: Routledge. Dryden, W. (2018). Very Brief Therapeutic Conversations. Abington, Oxon: Routledge. Dryden, W. (2019a). Single-​Session Therapy:  100 Key Points and Techniques. Abington, Oxon: Routledge. Dryden, W. (2019b). REBT in India: Very Brief Therapy for Problems of Daily Living. Abington, Oxon: Routledge. Dryden, W., DiGiuseppe, R., & Neenan, M. (2010). A Primer on Rational Emotive Behavior Therapy, Third Edition. Champaign, IL: Research Press. Ellis, A. (1989). Ineffective consumerism in the cognitive-​behaviour therapies and in general psychotherapy. In W. Dryden & P. Trower (Eds.), Cognitive Psychotherapy: Stasis and Change (pp. 159–​174). London: Cassell. Ellis, A. (1994). Reason and Emotion in Psychotherapy, Revised and Updated Edition. New York: Birch Lane Press. Ellis, A. (2002). Overcoming Resistance: A Rational Emotive Behavior Therapy Integrated Approach, Second Edition. New York: Springer. Ellis, A., & Joffe, D. (2002). A study of volunteer clients who experienced live sessions of rational emotive behavior therapy in front of a public audience. Journal of Rational-​Emotive & Cognitive-​Behavior Therapy, 20, 151–​158. Hoyt, M.F. (2011). Foreword. In A. Slive & M. Bobele (Eds.), When One Hour Is All You Have: Effective Therapy for Walk-​in Clients, (pp. xix–​xv). Phoenix, AZ: Zeig, Tucker, & Theisen. Hoyt, M.F., Bobele, M., Slive, A., Young, J., & Talmon, M. (Eds.). (2018). Single-​Session Therapy by Walk-​In or Appointment: Administrative, Clinical, and Supervisory Aspects of One-​at-​a Time Services. New York: Routledge. Hoyt, M.F., & Talmon, M. (Eds.). (2014). Capturing the Moment: Single Session Therapy and Walk-​in Services. Bethel, CT: Crown House Publishing Ltd. Keeney, H., & Keeney. B. (2014). Deconstructing therapy. Case study of a single session crisis intervention. In M.F. Hoyt & M. Talmon (Eds.), Capturing the Moment: Single Session Therapy and Walk-​In Services (pp. 441–​461). Bethel, CT: Crown House Publishing. Keller, G., & Papasan, J. (2012). The One Thing: The Surprisingly Simple Truth Behind Extraordinary Results. Austin, TX: Bard Press. Kellogg, S. (2015). Transformational Chairwork:  Using Psychotherapeutic Dialogues in Clinical Practice. Lanham, MD: Rowman & Littlefield. Ratner, H., George, E., & Iveson, C. (2012). Solution Focused Brief Therapy: 100 Key Points and Techniques. Hove, East Sussex: Routledge. Simon, G.E., Imel, Z.E., Ludman, E.J., & Steinfeld, B.J. (2012). Is dropout after a first psychotherapy visit always a bad outcome? Psychiatric Services, 63(7), 705–​707. Slive, A., & Bobele, M. (Eds.). (2011). When One Hour is All You Have: Effective Therapy for Walk-​in Clients. Phoenix, AZ: Zeig, Tucker & Theisen.

 63

References  63 Slive, A., & Bobele, M. (2018). The three top reasons why walk-​in single sessions make perfect sense. In M.F. Hoyt, M. Bobele, A. Slive, J. Young, J., & M. Talmon, (Eds.), Single-​Session Therapy by Walk-​In or Appointment: Administrative, Clinical, and Supervisory Aspects of One-​at-​a Time Services (pp. 27–​39). New York: Routledge. Talmon, M. (1990). Single Session Therapy: Maximising the Effect of the First (and Often Only) Therapeutic Encounter. San Francisco: Jossey-​Bass. Young, J. (2018). SST:  The misunderstood gift that keeps on giving. In M.F. Hoyt, M. Bobele, A. Slive, J. Young, & M. Talmon, (Eds.), Single-​Session Therapy by Walk-​In or Appointment: Administrative, Clinical, and Supervisory Aspects of One-​at-​a Time Services (pp. 40–​58). New York: Routledge. Young, K. (2018). Change in the winds: The growth of walk-​in therapy clinics in Ontario, Canada. In M.F. Hoyt, M. Bobele, A. Slive, J. Young, J., & M. Talmon, (Eds.), Single-​Session Therapy by Walk-​In or Appointment:  Administrative, Clinical, and Supervisory Aspects of One-​at-​a-​Time Services (pp. 59–​71). New York: Routledge.

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Index

Note: Page numbers in bold refer to tables. ABC framework 6, 7, 8, 11, 21, 30, 48 adversities 6, 7, 30–​33, 47–​48, 49–​51, 52; REBT 7, 8, 9, 12, 23, 29 anxiety 48, 49 appointments 13, 36, 39 Arts University, Bournemouth (AUB), UK 39, 40–​43 attitude change see change attitudes 6, 7, 9, 11, 33, 35, 50; flexible/​non-​extreme 6, 8, 9, 33, 50–​51; rigid/​extreme 6, 8, 9, 30, 50 basic attitudes 7, 9, 50 Battino, R. 15 beliefs 6–​7, 8, 50 Bernard, M.E. 23 Bobele, M. 36–​37 Bouverie Centre, Victoria, Australia 44 brief intermittent psychotherapy 14

DROs (doubts, reservations or objections) 26, 51 Dryden, W. 6, 7, 17, 19, 27, 34–​35, 44; counselling services 41, 43; OAAT Therapy 17, 37, 45–​52, 53, 54; Very Brief Therapeutic Conversations 17, 19 Ellis, A. 5, 6, 7, 13, 19, 21, 22, 25 emotions 9, 23, 26–​27, 30, 48, 49, 51 external resources 24–​25, 42, 47, 54 feedback 12 flexible/​non-​extreme attitudes 6, 8, 9, 33, 50–​51 Fran (dissertation anxiety example) 30–​31, 32, 34, 35, 49 Friday Night Workshops 13 generalisation 11, 23–​24 goals 12, 21–​22, 30, 32–​33, 49, 50

chairwork 33 change 10–​11, 12, 24–​25, 34–​35, 50–​51 client empowerment 24 client plans 17, 27, 43, 46, 51–​52, 53 client strengths 16, 24, 42, 47, 52, 54 client summaries 28, 52 counselling services 39, 40–​43 Cummings, N.A. 14

healthy attitudes 33, 35 healthy negative emotions (HNE) 9, 49, 51 help according to availability 1, 2–​3, 36 help according to need 1, 3, 36 helping pathways 1, 2–​3, 36 homework assignments 11, 27, 35, 51 Hoyt, M. 13

de Shazer, S. 21, 46 distorted inferences 12, 29 disturbances 6, 9–​10, 11

Imel, Z.E. 19 inferences 7, 12, 29, 30 informed consent 11

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Index  65 in-​session practice  27, 51 interventions 23 irrational beliefs 6, 7–​8 Keeney, B. 16 Keeney, H. 16 Ludman, E.J. 19 National Health Service (NHS), UK 36 negotiated solutions 16, 17, 22 OAAT (one-​at-​a-​time) Therapy 3–​4, 13–​14, 17, 18–​19, 36, 44, 45–​52, 53–​54; appointments 39; counselling services 39, 40–​43; generalisation 24; private practice 43–​44; REBT-​based 29, 30, 32–​33, 35, 55–​60; walk-​in therapy services 36, 37, 38 objectives 12 Petra (guilt-​based indecision example) 1–​3, 36 power of ‘now’ 15 private practice 43–​44 problem solving 11, 20, 21, 25, 47 rational beliefs 6, 8 rationality 6, 7 REBT (Rational Emotive Behaviour Therapy) 3, 4, 5–​7, 8–​12, 24, 25, 35, 47, 48, 50, 51; adversities 7, 8, 9, 12, 23, 29 REBT-​based OAAT Therapy 29, 30, 33, 35, 55–​60; adversities 29, 30, 32–​33; goals 30, 32–​33 REBT therapists 6, 10–​12, 19, 20, 21, 22–​23, 24–​25, 26, 27, 28 resources 16, 24–​25, 42, 47, 54 rigid/​extreme attitudes 6, 8, 9, 30, 50

Sam (REBT-​based OAAT Therapy example) 55–​60 Simon, G.E. 19 single-​session demonstrations 13, 17, 19 Single-​Session Integrated Cognitive Behaviour Therapy (SSI-​CBT)  17, 44 single-​session mindset see SST mindset situational ABC model 9, 11 Slive, A. 36–​37 SST (Single-​Session Therapy) 1, 13, 15, 18, 21, 22, 23, 24, 26, 39–​40 SST mindset 14, 15–​17, 20, 24 SST/​OAAT Therapy 14–​17, 18, 19, 20, 23, 24, 25–​26, 27, 28, 33, 38, 44 Steinfeld, B.J. 19 Talmon, M. 13, 43 therapeutic change see change therapeutic goals see goals unhealthy attitudes 33 unhealthy negative emotions (UNE) 9, 30, 48 values 22–​23 Very Brief Therapeutic Conversations (VBTCs) 17, 19 walk-​in therapy services 3, 36–​39 Windy’s Magic Question (WMQ) 32, 48 Windy’s Review Assessment Procedure (WRAP) 33, 34, 50 working alliance 11, 19 Young, J. 1, 44

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