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Single-Session

Integrated CBT

Until quite recently, therapist training was predicated on the notion


that therapy is an ongoing process. Single-Session Integrated CBT
(SSI-CBT) questions this. In this book, Windy Dryden takes long
standing research on SSI therapy and transfers it to the field of CBT
in a timely and conceptual application. Based on his extensive work
demonstrating the benefits of single-session CBT to public and pro-
fessional audiences, Dryden has developed a single-session approach
for work in the therapy and coaching fields.
Comprising 30 key points, and divided into two parts Theory
and Practice this concise book covers the key features of SSI-
CBT. It will offer essential guidance for students and practitioners
experienced in CBT, as well as practitioners from other theoretical
orientations who require an accessible guide to the distinctive theo-
retical and practical features of this exciting new approach.

Windy Dryden is in full-time 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. Windy has worked in psychotherapy for more
than 40 years and is the author and editor of over 200 books.
CBT Distinctive Features
Series Editor: Windy Dryden

Cognitive behaviour therapy (CBT) occupies a central position in the move


towards evidence-based practice and is frequently used in the clinical envi-
ronment. Yet there is no one universal approach to CBT and clinicians speak
of first-, second-, and even third-wave approaches.

This series provides straightforward, accessible guides to a number of CBT


methods, clarifying the distinctive features of each approach. The series edi-
tor, Windy Dryden successfully brings together experts from each discipline
to summarise the 30 main aspects of their approach divided into theoretical
and practical features.

The CBT Distinctive Features Series will be essential reading for psycho-
therapists, counsellors, and psychologists of all orientations who want to
learn more about the range of new and developing cognitive behaviour
approaches.

Titles in the series:


Compassion Focused Therapy by Paul Gilbert
Constructivist Psychotherapy by Robert A. Neimeyer
Dialectical Behaviour Therapy by Michaela A. Swales and Heidi L. Heard
Functional Analytic Psychotherapy by Mavis Tsai, Robert J. Kohlenberg,
Jonathan W. Kanter, Gareth I. Holman and Mary Plummer Loudon
Metacognitive Therapy by Peter Fisher and Adrian Wells
Mindfulness-Based Cognitive Therapy 2nd Edition by Rebecca Crane
Narrative CBT by John Rhodes
Rational Emotive Behaviour Therapy by Windy Dryden
Rational Emotive Behaviour Therapy 2nd Edition by Windy Dryden
Schema Therapy by Eshkol Rafaeli, David P. Bernstein and Jeffrey Young
Trial Based Cognitive Therapy by Irismar de Oliveira
Dialectical Behaviour Therapy 2nd edition by Michaela A. Swales and
Heidi L. Heard
Single-Session Integrated CBT by Windy Dryden

For further information about this series please visit


www.routledge.com/CBT-Distinctive-Features/book-series/DFS
Single-Session
Integrated CBT

Distinctive Features

Windy Dryden
First published 2017
by Routledge
2 Park Square, Milton Park, Abingdon, Oxon OX14 4RN

and by Routledge
711 Third Avenue, New York, NY 10017

Routledge is an imprint of the Taylor & Francis Group,


an informa business

2017 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


Names: Dryden, Windy, author.
Title: Single session integrated CBT : distinctive features / Windy
Dryden.
Other titles: CBT distinctive features series.
Description: London ; New York : Routledge, 2017. | Series: CBT
distinctive features series | Includes bibliographical references.
Identifiers: LCCN 2016017946 | ISBN 9781138639522 (hardback) |
ISBN9781138639591 (pbk.) | ISBN 9781315623122 (ebook)
Subjects: | MESH: Cognitive Therapymethods | ProfessionalPatient
Relations
Classification: LCC RC489.C63 | NLM WM 425.5.C6 | DDC 616.89/
1425dc23
LC record available at https://lccn.loc.gov/2016017946

ISBN: 978-1-138-63952-2 (hbk)


ISBN: 978-1-138-63959-1 (pbk)
ISBN: 978-1-315-62312-2 (ebk)

Typeset in Times New Roman


by Apex CoVantage, LLC
Contents

Introduction 1

Part 1 THEORY 9
1 Single-session Integrated CBT (SSI-CBT):
What it is and some basic assumptions 11
2 Working alliance theory: A generic framework
for SSI-CBT 17
3 People largely create and maintain their
problems by a range of cognitive-behavioural
factors 23
4 As far as possible clients should be helped to
deal healthily with the adversity involved in
their problem, whether real or inferred 29
5 Human beings have the capability to help
themselves quickly under specific circumstances 37
6 It is important to privilege your clients
viewpoints in SSI-CBT 41
7 Who can benefit from SSI-CBT? 45
8 Contraindications for SSI-CBT 59
9 A focus on both problems and goals is
important in SSI-CBT 63

v
CONTENTS

10 Carry out a full assessment and do as


much case formulation as you can in
the time available 69
11 In SSI-CBT it is possible to help clients
identify and deal with a central mechanism
responsible for the existence of their problems 73
12 The persons subsequent responses to their
first response are often more important than
the first response itself 79
13 It is important to draw upon a range of client
variables in SSI-CBT 85
14 Helpful client characteristics for SSI-CBT 89
15 Helpful therapist characteristics for SSI-CBT 97

Part 2 PRACTICE 103


16 Good practice in SSI-CBT 105
17 An overview of the SSI-CBT process 117
18 The first contact 121
19 The pre-session phone-call 125
20 The face-to-face session. 1: Beginning 137
21 The face-to-face session. 2: Creating a focus 141
22 The face-to-face session. 3: Understanding
the target problem 147
23 The face-to-face session. 4: Setting a goal 155
24 The face-to-face session. 5: Identifying
the central mechanism 167
25 The face-to-face session. 6: Dealing
with the central mechanism 173
26 The face-to-face session. 7: Making an impact 181
27 The face-to-face session. 8: Encouraging
the client to apply learning inside and
outside the session 191
28 The face-to-face session. 9: Summarizing,
tidying up loose ends and the clients
commitment to the future 197

vi
CONTENTS

29 After the face-to-face session: Reflection,


the recording and the transcript 203
30 The follow-up session and evaluation 205

References 213
Appendix 1 217
Index 221

vii
Introduction

In this introduction, I place single-session therapy (SST) in its recent


historical context and outline the reasons why I became interested
in this way of working that culminated in my developing what I call
Single-Session Integrated Cognitive Behaviour Therapy (SSI-CBT).

Single-session therapy: some recent history

This book adds to the growing literature on single-session therapy


(SST) that has blossomed since Moshe Talmons (1990) seminal
book on the subject. Two recent conferences on single-session work
and walk-in clinics (where a lot of this work takes place) have been
held in Australia and Canada, which attests to the international inter-
est that this way of working has attracted. A collection of papers
presented at the first of these international conferences entitled
Capturing the Moment has recently appeared, edited by Hoyt and
Talmon (2014a), two leading figures in the SST field. Much of the
work in SST originated in therapy with families where, due to the
difficulty of convening family members in ongoing therapy, brief
interventions were developed to take advantage of the time when
these members did attend.

1
INTRODUCTION

Up until quite recently, therapist training was predicated on the


notion that therapy is an ongoing process and that people attending
for only one or two sessions were considered to be dropouts from
the process. People in the SST field have consistently questioned this
notion. Talmon (1990), for example, reports on informal retrospec-
tive research that he carried out on 200 of his patients who attended
for only one session. He found that 78 per cent of this group said
that they had got what they wanted from attending therapy and only
10 per cent said that they did not like the therapist or the outcome
of therapy. Following on from that, Hoyt et al. (1990) carried out
a prospective study on planned single-session therapy with 60 cli-
ents, 58 of whom were reached on follow-up. Of that final sample
of 58, 34 did not require further therapy, 88 per cent reported much
improvement or improvement and 79 per cent thought that SST
was sufficient for them. This work suggested that the old adage that
people only attending for a single session of therapy can be con-
sidered to be dropouts could be challenged and a new definition
of dropouts from therapy was offered tongue-in cheek: A drop-
out from therapy is someone leaving therapy before their therapist
believes they should.1 Once it was accepted that productive work
could be achieved in a single session many people began to explore
the idea of designing SST, leading to different developments depend-
ing upon therapeutic setting and orientation.
With regard to therapeutic setting, much SST occurs in walk-in
services (sometimes known as drop-in centres2) mentioned earlier.
These are mostly used by people who want to talk when they have
a need to and dont want to be encumbered by using ongoing ser-
vices. Although some of these clients do return, workers in these
services make the assumption that the session will be the only one
that they will have with the client and design the work accordingly.
In another therapeutic setting, demonstrations of therapy in front of
a live audience or captured on DVD are essentially single sessions as
both therapist and client know that they are not going to meet again.
It is my view that much productive work can be done in these ses-
sions and the work done in such demonstrations can usefully inform
more formal SST.

2
INTRODUCTION

With respect to therapeutic orientation, it is perhaps no surprise


that SST would appeal to theorists and practitioners of solution-
focused therapy (SFT) with its emphasis on building solutions and
on utilizing clients strengths rather than on problem solving and
addressing clients deficits. However, a wide variety of other thera-
peutic approaches have shown an interest in SST including CBT.
From a CBT perspective, st developed an effective single-session
approach to the treatment of a variety of phobias (see Davis III et al.,
2012) which was predicated on the idea that it was important for
the patient to stay in the phobic situation until their levels of anxi-
ety dropped markedly. This necessitated that the single session often
lasted significantly longer than the 50-minute therapeutic hour. As
can be seen, this approach while cognitive-behavioural in nature very
much relied on the patients direct experience of the phobic object.
This emphasis on experience is very much a feature of another CBT
single-session treatment approach pioneered by Angela Reinecke
(e.g. Reinecke et al., 2013) who modified a standard panic disorder
treatment protocol (see Salkovskis et al., 1999). After explaining the
CBT model of panic disorder and in particular the role of safety-
seeking behaviour and the importance of exposure to the feared
situation without the use of such behaviour, patients were given an
immediate opportunity to practise this in a relevant situation. Very
promising results have emerged from this single-session treatment.

Single-session therapy: a personal journey

My own interest in developing what I call Single-Session Integrated


Cognitive Behaviour Therapy (SSI-CBT) emerged from a num-
ber of sources. Like many counsellors who trained in the 1970s, it
was almost obligatory to watch the Gloria films. Here, a client,
Gloria, was interviewed by three therapists demonstrating their
own approach to therapy. What was remarkable about this series of
films was that each of the therapists was the founder of the therapy
approach being demonstrated: Carl Rogers (the founder of what is
now known as Person Centred Therapy), Fritz Perl (the founder of

3
INTRODUCTION

Gestalt Therapy) and Albert Ellis (the founder of what is now known
as Rational Emotive Behaviour Therapy).
Although not apparent at the time, these interviews were essen-
tially examples of single-session therapy since Gloria did not have
any further sessions with any of the therapists.3 There were two fur-
ther series of such films with clients known as Kathy and Richard,
which, while not having the same impact on the field that the Gloria
films had, did show me what could be achieved in a single session by
representatives of different cognitive-behavioural approaches. Thus,
Arnold Lazarus (the founder of Multimodal Therapy, an approach
rooted in CBT), Aaron T. Beck (the founder of Cognitive Therapy)
and Donald Meichenbaum (a leading proponent of Cognitive Behav-
iour Modification) all worked effectively in the single session that
they had with their respective clients.
Another important influence on my interest in single-session work
was the live sessions carried out by Albert Ellis at his famous Fri-
day Night Workshops.4 At these workshops, carried out every Friday
evening when Albert Ellis was in town at his Institute in New York,
Ellis interviewed two people on a particular emotional problem, after
which he and the client answered questions from members of the
audience, who would also make pertinent observations.5 Research
done by Ellis and his wife to be, Debbie Joffe, indicated that vol-
unteers often did receive substantial help from these brief single
sessions from Ellis, but also most of them found the suggestions
offered by members of the audience useful (Ellis and Joffe, 2002).
When he was alive, Ellis claimed that members of the audience were
also helped by listening to these single sessions, although this has
yet to be studied.
My interest in the Friday Night Workshops led me to serve as the
therapist at some of these workshops, both while Ellis was alive and
after his death6 during my many visits to the Albert Ellis Institute.
From this experience, I discovered that I was very much drawn to
working within a single-session format and from the informal feed-
back that I got from clients and members of the audience it appeared
that my work was appreciated. Following on from this, then, I have
given demonstrations in front of an audience of what is effectively

4
INTRODUCTION

single-session therapy in that the client and I only have one session
in a number of different settings and countries.
Thus, whenever I give a workshop on a topic, I demonstrate
how I work therapeutically with one or more volunteers who have
a problem with the topic under consideration or, if I am giving a
more general workshop, volunteers are invited to come forward and
discuss a problem of their own choosing. The format is generally
the same and derives from the Friday Night Workshop format with
an interview, followed my observations and questions put to me as
therapist and/or to the client by members of the audience. In addition,
I do two things. First, I digitally record the interview and offer a copy
to the client.7 Second, I have the recording transcribed and offer the
transcription to the client. I keep a copy of both of these and con-
sult them both as a way of learning from what I actually do and as
a way of supervising myself. I have incorporated both the digital
voice recording (DVR) and the transcript into the Single-Session
Integrated Cognitive Behaviour Therapy (SSI-CBT) package that I
have devised and which I will describe in this book.
I mentioned earlier that I was influenced by the Gloria-Kathy-
Richard trilogy of films where CBT and non-CBT ways of working
were demonstrated by leading therapists. I have subsequently made
a number of DVD demonstrations of my doing therapy with vol-
unteer clients with problems of procrastination and guilt, two areas
in which I am interested. All these live and recorded demonstration
single sessions have helped me over the years to refine my approach,
culminating in the development of SSI-CBT.
So far I have discussed those influences on my ideas about SST
that were predominantly demonstrative in nature. In addition, these
ideas have also been shaped by what has happened in everyday prac-
tice. First, like many people in the SST field, I have been struck by
the number of people over the years who have made an appointment
at the end of the first session and have then cancelled it, saying
that on reflection the first session was sufficient. While I have not
canvassed these people from my caseload as comprehensively as
Talmon (1990) did, those who volunteered reasons for not returning
pointed to the first session helping them to do such things as: putting

5
INTRODUCTION

things into perspective, giving them a different way of thinking


about the problem and its relevant factors and seeing that they could
deal with issues involved better than they thought they could. As
someone steeped in the cognitive-behavioural model, these reasons
pointed to what could be done quickly if the conditions were right.
Second, I have noticed over the years that some people use ther-
apy very briefly, but do so at various points over a long period of
time. Thus, I have seen a number of clients who come for one or
two sessions and then stop, returning a long time later to discuss
other issues and do so again very briefly. These people seem to
benefit from a very brief intervention at different points of the life
cycle. I have had to modify my practice to accommodate these peo-
ples therapeutic needs and have been open to doing this rather than
trying to get them to fit into an ongoing therapy Procrustean bed.
Finally, I have encountered a variety of situations that have meant
that if I took on the person, then I would only see them for one ses-
sion. First, a number of people have wanted to see me for one session
because they would only be in London for a very short time and
wanted to consult me when they were in town. Second, a number
of people who are in therapy have wanted a second opinion on their
situation or their therapists have recommended that I see them for
such an opinion. Third, people who have heard about CBT want to
have a taste of it before committing themselves to a longer course of
treatment (and not necessarily with me) and thus will only commit
themselves to one taster session. Because I have been happy to
accommodate all of these requests, I have had to modify my practice
accordingly.
In this introduction, I have provided a brief historical context
of SST and discussed what has influenced my personal interest in
this field culminating in my developing an approach that I have
called Single-Session Integrated Cognitive Behaviour Therapy
(SSI-CBT). Let me begin by describing its theoretical framework
in the first part of this book before considering its practice in the
second part.

6
INTRODUCTION

Notes

1 The source of this humorous definition is not known.


2 These services are sometimes referred to as drop-in services. The use of
this term may not be accidental. If someone drops-in for a single session,
they can hardly be said to drop-out if they do not return!
3 Gloria did, however, correspond with Carl Rogers after her session with
him (Burry, 2008).
4 These were initially billed under the heading Problems of Living to con-
vey the idea that help was being provided for everyday problems rather
than for clinical problems.
5 And sometimes not so pertinent observations!
6 Since Ellis died, the tradition of carrying out single sessions of REBT in
front of a public audience has continued under the new heading of Friday
Night Live. A number of trained and experienced REBT practitioners
serve as the therapist at these events on a rotational basis.
7 To get the digital voice recording (DVR) of the session, the person has
to email me requesting the copy which I send via a Cloud service which
provides the client with a download link. Such recordings are too large to
send by email attachment.

7
Part 1

THEORY
SINGLE-SESSION INTEGRATED CBT (SSI-CBT)

1
Single-session Integrated CBT (SSI-CBT):
What it is and some basic assumptions
When I developed a cognitive-behavioural approach to single-session
therapy, I did so mainly to crystallize my own way of working that
I had developed from the experiences I outlined in the introduction.
However, I also wanted to outline a framework that other CBT ther-
apists could use who wanted to do single-session therapy in their
own way. In this book I will discuss the general framework while
illustrating the points with my own particular approach. When I dis-
cuss the general framework I will refer to it as SSI-CBT and when
I discuss my specific approach I will refer to it as SSI-CBT (WD).
My main goal is to focus on SSI-CBT, but many of the examples are
taken from SSI-CBT (WD)
While CBT therapists who wish to use a single-session approach
will no doubt develop their own format, at the moment I conceptual-
ize SSI-CBT as having four points of contact between you1 and your
client: (1) the first contact when the person seeking help makes con-
tact with you, the therapist, offering help; (2) if it is reasonably clear
that SSI-CBT may be the appropriate intervention what follows is a
more extended pre-session contact (usually by phone), the purpose
of which is to formalize this decision and to help you both get the
most out of (3) the single face-to-face session and approximately
three months later (4) a follow-up session takes place. At any point,
it may be clear that the person may need more therapy, in which case
you may offer this and when you do, the work is no longer consid-
ered to be single-session therapy. It is important to remember at all
times that client welfare is more important than therapist allegiance
to single-session work.
You may wonder why an intervention with four points of contact
is regarded as single-session therapy. In my view, SSI-CBT can be
11
THEORY

regarded as a single-session approach to therapy because it conforms


to Talmons (1990: xv) definition of SST: Single-session therapy
is defined here as one face-to-face meeting between a therapist and
a patient with no previous or subsequent sessions within one year.
Note that Talmons definition allows for the work to be completed
within one year, which is the case with SSI-CBT and that it does not
preclude other forms of therapist-client which is not face-to-face;
this is also true of SSI-CBT. The problem with Talmons defini-
tion is that if a therapist and client have one face-to-face session
but weekly telephone contact for eleven months, then this could be
regarded as SST. Obviously this is nonsense. So, my own defini-
tion of SST would be: One main face-to-face meeting between a
therapist and a client with no previous or subsequent main sessions
within one year; up to two non-face-to-face brief meetings prior to
the main session to arrange and get the most out of the main session;
and one follow-up session.

What is SSI-CBT?

How can single-session integrated cognitive-behaviour therapy


(SSI-CBT) be summed up in a nutshell? I think the approach is char-
acterized by the following:

It is a perspective on SST that is broadly CBT in its foundations


(from all waves). In my view CBT is a tradition, not an approach
and SSI-CBT draws from a variety of CBT approaches.
SSI-CBT also draws upon relevant work from outside CBT.
This in my approach to single-session therapy that I refer to as
SSI-CBT (WD), I am influenced by, amongst others, the work
of Moshe Talmon (1990), solution-focused therapy (e.g. Ratner
et al., 2012), pluralistic therapy (Cooper and McLeod, 2011),
transformational chairwork (Kellogg, 2015) and strengths-
based approaches (e.g. Duncan et al., 2004).
It recognizes the importance of behaviour and putting learning
into practice.

12
SINGLE-SESSION INTEGRATED CBT (SSI-CBT)

It recognizes the impact of a variety of cognitions (e.g. infer-


ences, beliefs/schemas) expressed in a number of ways (words
and images) at different levels of awareness.
It emphasizes the importance of emotional impact.
It highlights the importance of the client taking away new mean-
ing in a form that is memorable to them and which can be used
in appropriate situations.
It is not a single approach to single-session work.

The basic assumptions of SSI-CBT

Both the general SSI-CBT approach and my own specific SSI-CBT


(WD) approach are underpinned by a number of theoretical assump-
tions that it is important for me to explicate so that you understand
the foundation of this way of working.

This is it
An important assumption of all forms of SST is that the time you have
with a client within this format is it and that within the constraints
of the format this is all you have and therefore both parties need to
appreciate this and work determinedly to get the most out of this time.

Its all here


If SSI-CBT were a play then you and your client are the two pro-
tagonists and the context plays an important role in determining the
focus of the action. These three ingredients are all that is necessary to
help both parties get the most out of the process. Thus, its all here.

Focus on both the here and now and the future


What makes CBT an approach that is a good fit with a single-session
format is its present-centred and future-oriented foci. While as an SSI-
CBT therapist you might ask questions about a clients past, this would

13
THEORY

be to discover what the person has tried that was not effective in which
case you would distance yourself from this, going forward and what
the person has done that has been helpful in which case you might
wish to capitalize on this, going forward. Generally, however, you
will wish to find out what the current issues are that the person wants
help with and what the person will accept as an acceptable and realistic
goal, given the single-session nature of the work.

Therapy starts before the first contact and will


continue long after the final contact
It is tempting to think that while SSI-CBT is very brief that all its
therapeutic potential is realized through the contact between thera-
pist and client. This is not the case and as an SSI-CBT therapist it is
important that you appreciate the therapeutic value of extra-therapy
variables. Thus, just deciding that one wishes to address ones issues
can be a powerful therapeutic force as can contact with other people
once such a decision to be made.

Howard decided that he wanted to deal with his feelings of


irritability and of being out of control after experiencing two
personal losses in quick succession. We ascertained that he
would be a good candidate for SSI-CBT and booked a pre-
session contact phone call (see Chapter 19). Before we spoke
on the phone, Howard met with some of his friends and told
him how he felt after these losses. His friends all said that they
had felt similar feelings after experiencing loss and this helped
Howard to normalize some of his feelings even before we had
initiated the SSI-CBT process.

Therapy occurs over the persons life cycle.


Its not a one-shot deal
Over the course of our lives when we are physically ill, we will
in the first instance consult our GP who will manage our problem
unless it appears more serious, in which case we will be referred for

14
SINGLE-SESSION INTEGRATED CBT (SSI-CBT)

further investigation. However, this model of consulting a therapist


as and when help is needed over the life cycle is regarded more sus-
piciously. However, SST therapists are generally comfortable with
the idea of such consultations and will endeavour to help the person
as quickly as possible within the SST framework.

Build on whats there, dont start from scratch


Clients generally come to SSI-CBT with a history of trying vari-
ous things to help them solve their problems. Rather than start from
scratch, it is an assumption of SST that you can build on what clients
have already tried to do to solve their problem, encouraging them to
desist from continuing to use strategies that have not worked and to
use strategies that have yielded some benefit and can be developed.

You do not have to rush


While time is at a premium in SST, the most effective single-session
therapists seem to take their time and dont rush the process. It is
much more important to work at the clients pace and to help the per-
son to stay focused on their major issue and the related goal/solution.
If you rush the process you will tend to be focused more on what you
should cover than on helping the client where they are.

Clients are helped most by taking away one


thingfrom the work rather than everything
including the kitchen sink
There is a temptation, if you are working within a single-session
framework, to want clients to go away with as much as possible
so that they get the most out of the process. I call this the Jew-
ish mother syndrome which points to the idea that the archetypical
Jewish mother is only happy if their prodigal children leave after a
visit, having eaten everything put in front of them, which is usually
a considerable amount and more food for later! In the same way
as a well-digested meal is more satisfying than leaving fully stuffed,

15
THEORY

single-session therapy clients who leave the process having digested


one important therapeutic point, principle or method will generally
get more out of the process than those armed with a plethora of such
points, principles and/or methods, but without having digested any
of them. Thus, aim to equip your SSI-CBT clients accordingly and
resist the urge to throw everything including the kitchen sink at them.

The power is in the client


While SSI-CBT makes a lot of demands on you to make skilful
interventions in a short period of time, the real power to make this
approach work lies with the client and to be effective as a SSI-CBT
therapist, keep this point very much at the forefront of your mind.
One of the best ways of implementing this point is to identify clients
strengths and to encourage them to use these throughout the brief
process and beyond. However, since you do have an important con-
tribution to make as a therapist, your real skill is to help your client
make use of your contribution, using their own strengths in doing so.

Expect change
In education there is a principle known as the Pygmalion effect. This
states that teachers who expect a lot from their students get more out
of them than do teachers who expect a lot less (Rosenthal and Jacob-
son, 1968). It is thus an assumption of SSI-CBT that clients who are
suited to this approach can get a lot from it. Thus, go into SSI-CBT
expecting change and convey this idea to your clients.
In the next chapter I will outline working alliance theory which I
consider to be a useful generic framework for SSI-CBT.

Note

1 Throughout this book I will address you, the reader, directly as if you are
already an SSI-CBT therapist. I felt most comfortable using this more
personal voice in this particular book and I hope that you dont mind.

16
WORKING ALLIANCE THEORY

2
Working alliance theory: A generic
framework for SSI-CBT
As is made clear in the title, Single-Session Integrated Cognitive
Behaviour Therapy (SSI-CBT) is based largely on the theory and
practice of cognitive behaviour therapy (CBT), a specific tradition
within the field of psychotherapy. However, as SSI-CBT is a flexible,
open approach, it draws on concepts, ideas, practices and theories that
can be found in other specific therapy traditions and in more generic
therapeutic frameworks. One such framework that is particularly
influential on the way that SSI-CBT therapists think about their work
and the way that they practise is known as working alliance theory.
Working alliance theory was developed by Ed Bordin (1979) who
argued that the practice of psychotherapy can be understood from the
perspective of three broad interlocking domains: bonds, goals and
tasks. In 2011, I added a fourth domain that I called views (Dryden,
2011). In this chapter, I will present and discuss the updated version
of working alliance theory and show how it influences the thinking
and practice of SSI-CBT therapists.

Bonds

Bonds refer to the interpersonal connectedness between you and


your client. There are several aspects of the bond domain that are
relevant to SSI-CBT.

Core conditions
The core conditions refer to the extent to which your client experi-
ences you as empathic, respectful and genuine in their encounters

17
THEORY

with you. SSI-CBT considers that it is important for you to be expe-


rienced in these ways by your client, but that it is usually insufficient
for change to occur unless this experience itself facilitates a relevant
change in the clients meaning system and/or behavioural system
that is considered to be the major goal of SSI-CBT.

Therapeutic style
The core style of SSI-CBT is active and directive. Here, you actively
direct your clients attention to the nature of their target problem
and related goal and the ways of thinking and behaviour regarded
as playing a major role in maintaining this problem. Then you work
actively to help the client develop a change preferably both in mean-
ing and behaviour that will facilitate goal achievement. While, it is
important for you as therapist to adopt an active-directive style from
the outset, it is equally important to strive to help your client to be as
active in the process as possible so that an outsider looking in would
see a dialogue between two equally participating persons. When you
are active and the client is passive or vice versa, the chance of pro-
ductive work taking place is diminished.

The therapist as authentic chameleon


Arnold Lazarus (1993) put forward the concept of the therapist as
authentic chameleon. By this he meant that effective therapists
are prepared to change their therapeutic style with different clients,
but do so authentically. For example, it is possible to practise SSI-
CBT with an informal or a formal style, with humour or without,
and using stories, metaphors and parables or without doing so. There
are no clear markers that can tell you which is the best style to use
with a particular client, although, here as elsewhere, the modifica-
tion of George Kellys (1955) first principle is useful to implement:
If you do not know something about the client, ask them, they may
tell you.1 Then if you implement the answer and gauge the clients
response, this will usually tell you whether or not you are on the
right track.

18
WORKING ALLIANCE THEORY

Views

The views domain concerns the understandings that both you and
your client have about the myriad issues concerning SSI-CBT. Leav-
ing aside issues such as fees and confidentiality, the important issues
that you both need to agree on if SSI-CBT is to be effective concern
the following.

The components of SSI-CBT


It is important that you both understand what the components are
with respect to SSI-CBT so that your client has accurate expectations
of the process. As I conceptualize it, SSI-CBT has the following
components:

The initial point of contact. Here, the person contacts you and
you both consider the suitability of SSI-CBT for that persons
needs. If you both think that SSI-CBT is a possibility, you out-
line the costs of the entire process and the next point of contact
is arranged.
The pre-session phone contact. This contact lasts for about
20 to 30 minutes. Its purpose is to ascertain more definitely
whether or not SSI-CBT is suitable for the person and, if so,
you work with them so that you both can get the most out of
the major part of the process which is the face-to-face session.
This may involve you sending the client an email which might
summarize what was discussed and what the client needs to do
before the face-to-face session.
The face-to-face session. This contact lasts up to 50 minutes and
is where, in most cases, the bulk of the work is done.
The follow-up session. This session normally occurs about three
months after the face-to-face session and lasts up to 30 minutes
over the telephone.

While these four points of contact are part of my model of SSI-


CBT, other therapists models may vary in certain respects. The

19
THEORY

important point from the perspective of the views domain of the


working alliance is that your client is clear about what they are get-
ting and have given their consent to this.

The availability of additional sessions


Some theorists in the SST field argue that it is important to offer
single-session clients additional sessions if they need them later (e.g.
Talmon, 1990). In doing so, the argument goes, this relieves the ten-
sion that everything has to be achieved within one single session
which paradoxically enables the work to be done within this para-
digm. Others argue that it is important to be clear at the outset that
in SST only one session is being offered so that the client knows
exactly where they stand. From a working alliance perspective what
is important is that both you and your client are clear concerning
whether or not additional sessions are possible and that you proceed
based on your agreed understanding of this view.

The cognitive-behavioural conceptualization


SSI-CBT, by definition, employs a cognitive-behavioural conceptu-
alization of the clients problems and goals, although concepts from
other frameworks may be additionally employed. From a work-
ing alliance perspective, the work can proceed only if your client
indicates that the CBT view of their problem makes sense to them
and that they can make use of it. If not, SSI-CBT is unlikely to be
effective.

Goals
SSI-CBT is both problem focused and goal oriented. When goals are
considered from a working alliance perspective, what is important is
that both you and your client agree on the clients goals. While this
appears straightforward, it can be problematic when for example,
your client sets goals that are unrealistic given what can be realisti-
cally achieved from SSI-CBT. When this occurs, the extent to which

20
WORKING ALLIANCE THEORY

you can help the client scale back their goal will determine the suc-
cess of SSI-CBT. I will discuss the complexity of goals in SSI-CBT
and how to work productively with them in Chapters 9 and 23.

Tasks
Tasks are activities that both you and your client carry out in the
service of the clients goals. From a working alliance perspective,
important questions include the following:

Can your client understand your interventions and the active-


directive stance that you are taking?
Can your client engage actively in the SSI-CBT process?
Is your client prepared to engage with in-session tasks suggested
by you that may form a bridge between discussion in the session
and activity outside the session and that may have an emotional
impact on the client?

Affirmative answers to these questions indicate a strong alliance


in the task domain and are suggestive of a good outcome.
Developing and maintaining a good working alliance between
you and your client is paramount in SSI-CBT and if the only way you
can preserve that alliance is by straying outside the usual parameters
of CBT then I suggest that you do so.
In the next chapter, I will consider the assumption of SSI-CBT
that people largely create and maintain their problems by a range of
factors that are cognitive-behavioural in nature.

Note

1 Kellys (1955: 3223) first principle was: If you do not know what is
wrong with a person, ask him; he may tell you.

21
PEOPLE CREATE AND MAINTAIN THEIR PROBLEMS

3
People largely create and maintain
theirproblems by a range of
cognitive-behavioural factors
I mentioned in the previous chapter that Single-Session Integrated
Cognitive Behaviour Therapy (SSI-CBT) is best seen as an over-
arching framework that can accommodate different approaches with
the CBT tradition. While these therapists do differ in ways that I will
discuss a little later, they all ascribe to the idea that people largely
create and maintain their psychological problems by employing a
range of cognitive and behavioural factors.
Hayes (2004) argued that the development of CBT can be seen
according to a number of waves. In using the SSI-CBT frame-
work, first wave therapists, who are often seen as espousing a
non-cognitively oriented behaviour therapy, will emphasize factors
which explain the development and maintenance of psychological
problems through classical conditioning, associative learning and
positive reinforcement of disturbed responses.
Second wave CBT therapists will use the SSI-CBT framework
focusing much more on a range of cognitive factors at different levels
within the cognitive system (such as negative automatic thoughts,
thinking errors, dysfunctional assumptions and schemas) which
embodies the idea that goes back to Epictetus that people disturb
themselves not by things but by the view that they take of things.
Behaviour here is largely seen as what the person does on the basis
of holding these views. These therapists will seek to effect change
in the content of these cognitive factors with changes in behaviour
reinforcing this cognitive change.
Third wave CBT therapists will use the SSI-CBT framework
to consider factors that reflect peoples failed attempts to deal with

23
THEORY

normal cognitive and emotive responses to adversities deemed


problematic by the individual and which result in the person
adopting an overly critical stance towards self for these responses.
Third wave CBT therapists do not advocate that clients change
their so-called dysfunctional cognitive and emotional responses.
Rather, they provide a rationale for them to adopt a mindful and
compassionate acceptance of these responses with value-based,
goal-oriented behaviour being encouraged in the face of such
acceptance.
In practice, therapists probably draw on all three waves in devel-
oping their own integrated practice of CBT.

SSI-CBT (WD)

I have mentioned that my major task in writing this book is to show


how CBT therapists practising a variety of CBT approaches can use
the SSI-CBT framework. I also mentioned that I will illustrate the
points that I make by outlining how I practise SSI-CBT. I refer to
my approach as SSI-CBT (WD). So in this section, I will outline the
factors that I keep in mind when working with clients.

Rigid and extreme beliefs vs flexible


and non-extreme beliefs
My main allegiance in CBT is to Rational Emotive Behaviour
Therapy (REBT). The main theoretical tenet of this approach is that
people disturb themselves about adversity by the rigid and extreme
beliefs that they hold about adversity and if they are to respond to
such negative events they need to be helped to develop flexible and
non-extreme beliefs instead (Dryden, 2015). Thus, what I look for
within an SSI-CBT framework is an opportunity to focus on the
rigid and extreme beliefs that underpin my clients problems with a
view to helping them make these beliefs flexible and non-extreme.
If this is not possible then I will look for ways of helping the client

24
PEOPLE CREATE AND MAINTAIN THEIR PROBLEMS

to question any distorted inferences that they may be making in the


problem situations.

Jessica sought single-session therapy for her problems with


social anxiety. She was anxious because she believed that she
had to be interesting and that people would reject her if she
wasnt, which she regarded as terrible. My choice points were
to help Jessica develop a flexible belief about the possibility
of not being interesting, develop a non-extreme belief about
being rejected or to question her inferences (a) that she would/
not be interesting and (b) that people would reject if she wasnt
interesting.

Avoiding vs confronting issues


People often unwittingly maintain their problems by their attempts
to avoid them or to avoid the distress that their problems occasion.
This generally serves to keep them safe in the short term, but does
not help them in the long term. So in dealing with clients problems
within SSI-CBT, I generally look for the following:

ways in which clients avoid troublesome situations;


what clients do to keep themselves safe if they cannot escape
such situations, but without dealing with them constructively;
what clients tend to do to try to eliminate their troublesome
thoughts and emotions;
what clients do to over-compensate for their problems;
clients attempts to deal positively or neutrally with adversity.

Unhealthy vs healthy stances towards problems


When people develop problems the stance that they take towards
these problems either enables them to tackle them productively or
serves to give them an additional problem about their original prob-
lem. When the latter occurs, these additional problems are known

25
THEORY

as meta-problems. It sometimes occurs in SSI-CBT that when the


client is helped to tackle their meta-problem, this is sufficient to help
them to live productively, even when what they see as the original
problem is still present.

Colin sought help for what he saw as his oversensitivity. He


would become very emotional whenever he lost something
or someone of value to him. Colin felt ashamed about his
oversensitivity which, it transpired was his major problem.
When I helped Colin to accept himself as an ordinary person
who reacted more emotionally then he would have preferred
and to acknowledge that he was not a weak person, he was able
to stop ruminating about his over-responsiveness.

Behaviour towards others


Quite often people seek single-session therapy for help with interper-
sonal problems. How I deal with such situations is first to establish
whether or not the person is disturbing themself about the other per-
son and if so to deal with this first. Then I discover how they have
been behaving towards the other person, as well as how the other
person has been treating my client. My focus here is to ascertain if
my client is unwittingly perpetuating the problem by the way they
are behaving towards the other person and, if so, to try and help the
client bring about change by encouraging them to modify their own
behaviour rather than try to change the other person directly.

Discomfort intolerance vs discomfort tolerance


In my experience, the ability to tolerate what might be broadly
termed discomfort is important if sustained therapeutic change is
going to occur. Given this, I look for points where clients may hold
discomfort intolerance beliefs and encourage them to hold and act
on an alternative set of discomfort tolerance beliefs. A particular
type of discomfort intolerance refers to peoples perceived ability to
withstand their own disturbed feelings and is known in the literature

26
PEOPLE CREATE AND MAINTAIN THEIR PROBLEMS

as distress intolerance (Zvolensky et al., 2011). Such intolerance


leads people to try and tranquillize their distressed emotions and/or
avoid situations in which they experience such feelings and thus is
a major perpetuator of psychological problems. Helping clients to
tolerate their distress is, therefore, a major goal in SSI-CBT.
In the next chapter, I will discuss the principle of helping clients
to face their adversities in SSI-CBT.

27
CLIENTS SHOULD DEAL HEALTHILY WITH ADVERSITY

4
As far as possible clients should be
helped to deal healthily with the
adversityinvolved in their problem,
whetherreal or inferred
What adversities do clients discuss in SSI-CBT?

In my experience, SSI-CBT clients discuss similar adversities as do


clients in ongoing therapy. The ABC cognitive-behavioural model
of the emotions suggests what these adversities are. For our pur-
poses here, A stands for adversity (or negative event), B stands
for belief (or thinking) and C stands for the persons emotional
and behavioural response to the adversity. Beck (1976), in an early
work entitled Cognitive Therapy and the Emotional Disorders, laid
the blueprint for this model by outlining the kinds of adversities
that tend to be associated with each of the main emotional problems
for which clients seek help. In doing so, Beck (1976) introduced a
concept he called the personal domain. This is made up of people,
objects, concepts and ideas that are important to a person. It also
includes what is important to the person about themselves. I recently
developed this model (Dryden, 2009) and one way in which I did
so was to distinguish between two major realms of the personal
domain: the ego realm (which concerns the persons estimation of
themself ) and the discomfort realm (which concerns the persons
sense of comfort).
Basically the cognitive-behavioural model of the emotions states
that when clients present their emotional problems in SSI-CBT (at
C in the ABC model) they suggest what they are disturbed about
at A (i.e. what adversities they face or think that they face). Here is

29
THEORY

a list of the most common emotions that clients discuss in SSI-CBT


and the associated adversities.

Anxiety
When a client presents with anxiety, they tend to be anxious about
something that poses a threat to a central aspect of their personal
domain. The important element of this threat is that it is perceived to
be imminent. Common anxiety-related adversities in the ego realm
of the personal domain include:

failure;
rejection;
criticism;
disapproval; negative judgment from others;
disclosure of negative information about self;
lack of self-control.

Common anxiety-related adversities in the discomfort realm of


the personal domain include:

uncertainty concerning ones physical and/or mental well-being;


doubt about the existence of purity related to a core aspect of the
personal domain;
lack of self-control;
feeling uncomfortable.

Depression
When a client presents with feelings of depression, they tend to be
depressed about:

failure within their personal domain;


a loss from their personal domain;
undeserved plight experienced by self or others.

30
CLIENTS SHOULD DEAL HEALTHILY WITH ADVERSITY

The core difference between anxiety and depression here is that


in anxiety the adversity is imminent while in depression it is deemed
to have happened.

Guilt
When a client presents with feelings of guilt, they tend to feel guilty
about:

breaking one of their codes within the moral sphere of their per-
sonal domain;
failing to live up to one of their codes within the moral sphere of
their personal domain;
harming or hurting the feelings of others.

Shame
When a client presents with feelings of shame, they tend to feel
ashamed about:

falling very short of one of their ideals within their personal


domain;
revealing something shameful about themselves;
being judged negatively for a personal weakness within their
personal domain;
something shameful being revealed by or about someone with
whom one feels closely associated.

Hurt
When a client presents with hurt feelings, they tend to feel hurt
about:

being more invested in a relationship than the other person with


whom they are involved;

31
THEORY

being treated badly and undeservedly by another person with


whom they are involved.

Anger
When a client presents with feelings of anger, they tend to feel angry
about a number of adversities which include:

being frustrated;
being obstructed towards their goal;
someone breaking one of their personal rules;
them breaking one of their own personal rules (in self-anger);
another posing a threat to their self-esteem;
another disrespecting them;
being treated unjustly or seeing another person being treated
unjustly.

Jealousy
When a client presents with feelings of jealousy, they tend to feel
jealous:

when they think that a significant relationship that they have


(usually, but not exclusively romantic in nature) is being
threatened by someone elses interest in the person with
whom they are involved and/or by that persons interest in
someone else;
when they are faced with uncertainty or ambiguity with respect
to the above threat.

Envy
When a client presents with envy, they tend to feel envious:

when someone has something (e.g. an object, a relationship or a


job) that they want but dont have.

32
CLIENTS SHOULD DEAL HEALTHILY WITH ADVERSITY

When should you help clients deal with


adversities in SSI-CBT?

The salient question here is under what conditions should you, as


an SSI-CBT therapist, help the client deal head-on with adversities
rather than help them work around these adversities? The answer to
this question is complex, but in SSI-CBT (WD), I am guided by the
following principles.

The client is stuck in the face of the adversity


inquestion
As we will see presently, a client being stuck is a major positive
indication for SSI-CBT. Being stuck here means that the client
responds to the same type of adversity in the same manner and is
unable to move on. When this happens the goal of the intervention is
to promote movement in the client and this is best done, in my view,
by helping them face up to and deal directly with the adversity, if at
all possible.

The client reacts to the adversity with disturbed


feelings and/or unconstructive behaviour
As practitioners of Acceptance and Commitment Therapy (ACT)
note, the presence of negative feelings is not necessarily a sign that a
client needs help to deal with an adversity (e.g. Batten, 2011). How-
ever, if they respond with disturbed negative feelings and particularly
if this emotional response is accompanied by unconstructive behav-
iour then the client will generally need to be helped to deal more
constructively with the adversity. However, this certainly does not
preclude them experiencing negative emotions. One of the princi-
ples of REBT that underpins my own approach to SSI-CBT (WD) is
that healthy negative responses (feelings and behavior) to adversity
are based on the person holding flexible and non-extreme beliefs
about the adversity, while unhealthy negative responses to the same
adversity are based on the person holding rigid and extreme beliefs

33
THEORY

about the same adversity. Thus, I will only intervene if the persons
response to adversity is negative and unhealthy.

The clients main adversity is their response


totheirresponse to adversity
Humans are the only organism capable of disturbing themselves
about their own reactions to adversity. Sometimes this is their biggest
problem, particularly when they respond negatively, but healthily to
the adversity in the first place.

Marion lost her pet dog and felt sad about her loss. She cried a
lot and while she accepted that sadness was a normal response
to this loss, she felt ashamed that her feelings of sadness
remained with her for longer than she believed they should
have done.

In addition, a client may feel disturbed about a disturbed reac-


tion. This secondary disturbance needs to be targeted for change if
its presence prevents you from dealing with the clients primary dis-
turbance in SSI-CBT.

The client keeps responding unhealthily to adversity


even when they correct their distorted inferences
Within a single-session therapy framework, it is always tempting
to help people quickly by encouraging them to question their infer-
ences about the situations that they find troublesome, particularly
when it is clear that these inferences are distorted.

Dennis sought SSI-CBT for help with public speaking anxiety. It


quickly became clear that he was anxious about being thought
boring despite evidence to the contrary. The reality was that he
got excellent feedback on his public presentations. In a previous
ongoing therapy, Denniss therapist targeted for change his

34
CLIENTS SHOULD DEAL HEALTHILY WITH ADVERSITY

distorted inference that he was boring. However, while this


helped Dennis in the short-term, he kept returning to the idea
that he would give a boring presentation. In SSI-CBT, I took a
different tack and encouraged him to face his adversity directly
and to imagine that he did give a boring speech. I then helped
him to identify, examine and change the anxious-meaning he
put on this eventuality.

I am not recommending that SSI-CBT therapists never question


their clients inferences. Indeed, sometimes when a client considers
a new inferential point of view for the first time it can bring about
transformational change based on that aha moment deemed the
holy grail in SST (Armstrong, 2015).

A good friend and colleague of mine, Richard Wessler, tells of a


woman that he tried help deal with her unhealthy anger about
what she saw as her fathers intrusiveness. She would fly into
a rage whenever her father rang and asked her Noo, whats
doing? After getting nowhere by encouraging her to assume
that her inference of paternal intrusiveness was true and
helping her to deal with this adversity, Wessler encouraged her
to consider other meanings of her fathers behavior. The clients
aha moment came when Wessler asked her to consider her
fathers behaviour as his idiosyncratic opening interpersonal
gambit the modern equivalent being whassup and not as
evidence of his intrusiveness. While this new inference was
sustained, the question remains moot concerning what would
have happened in the future if the client had incontrovertible
evidence that her father was being intrusive. The point here is
that in this case working around the adversity was the best tack
that this therapist could have taken with this particular client,
at this moment in time.

However, my own view is that, whenever possible and feasible,


clients should be helped to deal healthily with adversities that they

35
THEORY

find troublesome. Otherwise, what they achieve from SSI-CBT may


be temporary. However, as we have just seen, there are exceptions
to this principle.
In the next chapter, I will discuss SSI-CBTs assumption that peo-
ple can help themselves quickly if the conditions are right.

36
HUMAN BEINGS CAN HELP THEMSELVES

5
Human beings have the capability
tohelp themselves quickly under
specificcircumstances
Albert Ellis (e.g. 2001), the founder of Rational Emotive Behaviour
Therapy (REBT), whom I consider to be one of the most impor-
tant influences on my career as a therapist, was fond of telling case
vignettes to make a clinical point. One of these vignettes comes to
mind whenever I talk about SSI-CBT and, in particular, our capacity
to help ourselves in a short period of time as human beings.

The woman, whom I will call Vera, had sought help for her
elevator phobia from Albert Ellis and because she could not
afford individual therapy sessions she joined one of Elliss
groups. While Vera accepted the idea that she needed to
confront her fear by going on elevators, she resisted acting on
this idea and the efforts of Ellis and her fellow group members
to identify and deal with all the obstacles that she erected to
prevent her from actually entering an elevator. Throughout
this, Vera maintained that she really wanted to overcome her
elevator phobia.
One day, Vera booked an individual session with Ellis on a
late Friday afternoon, which was a very unusual occurrence.
She had just heard that the company she worked for was
moving their office suite from the fifth floor of a skyscraper
to the 105th floor of the same building. Moreover, they were
moving over the weekend and planned to be up and running in
their new suite early Monday morning. Hitherto, Vera had been
able to climb the five flights of stairs, but there was no way, she
reasoned, that she could climb 105 flights of stairs every day.

37
THEORY

Vera was desperate to keep her job and implored Ellis to help
her deal with her fear so that she could take the elevator to
the 105th floor on Monday morning. Ellis told her that if she
wanted to achieve her goal then she would have to commit
herself to going up and down elevators in tall skyscrapers all
weekend and to accept the great discomfort of doing so. Vera
did just that until she had got over her fear. Repeated practice
proved effective as it would have done years earlier when Vera
first sought therapy, but she did not engage with it at that time.

Before Vera made a very rapid change after her company announced
the change of their office suite, you might be forgiven for thinking
that she was not capable of helping herself in a short space of time
with her elevator problem. However, it transpired that Vera did have
that capability, but only decided to use it under a particular set of
circumstances. These seemed to be as follows:

1. Knowledge

Vera knew what she needed to do to overcome her elevator phobia.


She had the requisite knowledge. A client knowing what to do to help
themselves with a problem is an important ingredient for change,
but, as we have seen with Vera, not a sufficient one. Vera knew what
she needed to do before the office suite move, but decided not to act
on that knowledge.

2. A committed reason to change

Before the office suite move, Vera claimed that she wanted to tackle
her elevator phobia, but her actions belied her words. My explanation
for this is that before the move she did not have sufficient reason to
address her problem properly, but afterwards she did. She consid-
ered that being able to get to work by elevator to the 105th floor was
the only way of retaining her job, which she was very keen to do,

38
HUMAN BEINGS CAN HELP THEMSELVES

and she further considered that the only way she could do that was to
overcome her elevator phobia. Before the move, she was prepared to
walk up to the fifth floor. If Vera decided to change jobs she would
not have changed her engagement with her problem. She would prob-
ably have remained half-hearted in her approach to tackling it.
Some might say that before the move Vera lacked sufficient moti-
vation to change. While I can understand this, my view is that the
concept of motivation is a little imprecise for our purposes as it
tends to encompass a reason to change and a state of feeling as when
someone says: I did not do it because I did not feel motivated to
do it. My view on Veras case is that she had a reason to change to
which she was fully committed. I call this having a committed reason
to change and when humans have this then they can do things that
they and others may not think that they are capable of doing.

3. Prepared to accept the costs of change

When Ellis told Vera that if she wanted to make a rapid change then
she would need to tolerate quite a lot of discomfort while undertak-
ing the repeated practice that this approach required, he was asking
her to consider whether or not she was prepared to accept the costs of
change. No gains, without pains, as Benjamin Disraeli said. Expe-
riencing discomfort is one of many costs that clients may encounter
when they change and it is important to help them to identify what
these costs are and to reflect on whether or not they are prepared to
accept the costs of change. Clients who want to make a rapid change,
but are not prepared to accept the costs of doing so, will not benefit
much from SSI-CBT.
These three ingredients knowledge, having a committed reason
to change and being prepared to accept the costs of change need to
be present for people to get the most from sts intensive one-session
treatment of single phobias (see Davis III et al., 2012). Indeed, if all
three are not present or their presence cannot be encouraged, then
clients who lack them may not be accepted into this intensive treat-
ment programme.

39
THEORY

Humans are capable of what Miller and Cde Baca (2001) have
called quantum change. These are sudden insights and spiritual-
type epiphanies that occur within a very short period of time but have
lasting positive effects. While such change rarely happens within a
SSI-CBT context, it does demonstrate our capability as humans to
make profound changes quickly and it is this that makes it a core
theoretical idea behind SSI-CBT.
In the following chapter, I will discuss the importance of privileg-
ing your clients viewpoint in SSI-CBT.

40
PRIVILEGE YOUR CLIENTS VIEWPOINTS

6
It is important to privilege your clients
viewpoints in SSI-CBT
I remember reading the following sentence in an abstract of a journal
article which has stayed with me. The study was looking at various
predictors of dropout and outcome in cognitive therapy for depres-
sion in a private practice setting (Persons et al., 1988: 557). The
sentence read as follows: In spite of significant improvement, 50%
of patients terminated treatment prematurely. Now while this state-
ment can be read a number of ways, it does show that a significant
number of clients in this study left therapy once they had made sig-
nificant improvement while the authors considered that these clients
had ended therapy prematurely. Of course, therapists have their views
concerning client functioning and dysfunctioning and these views are
coloured by professional knowledge. Maluccio (1979), in his classic
study, found that therapists were less happy than their clients were
when the latter terminated prematurely because, while the latter
were happy with what they achieved, the former could see all manner
of issues that needed to be dealt with, but werent. However, the point
here is that in single-session work, it is important to prioritize your
clients view over your own as therapist and while you may see areas
that your clients need to work on, it is important that you let them be
the principal judge of what it is in their interests to deal with.

Dropout

In a comprehensive review of client variables in therapy, Bohart


and Wade (2013) note that what complicates the literature on so-
called therapy dropout is that we have no agreed definition of

41
THEORY

premature termination or what they term early termination (ET). I


have already mentioned one rather tongue-in-cheek definition that:
dropout occurs when the client leaves therapy before the therapist
thinks that they are ready to. More seriously, Bohart and Wades
review shows that while quite a few clients most certainly do leave
therapy before they have benefited from the process, a good number
also seem to leave therapy because they have got what they wanted
from the process. Thus, Westmacott et al. (2010) found that clients
who terminated therapy without agreement with their therapists saw
their psychological distress as less severe when they left therapy
than when they entered, while their therapists rated their distress
as unchanged. This echoes Maluccios (1979) finding that clients
were happier with what they got from therapy than their therapists
were and thus left when they were ready to, but before their therapist
believed that they should.
Therapists distinguish between improvement that is clinically sig-
nificant and non-clinically significant, but clients tend not to make
such a distinction for themselves. Barrett et al. (2008), in their review,
conclude that some clients end therapy satisfied even when they have
not met their therapists criterion of having made clinically signifi-
cant change. Cahill et al. (2003) found that the majority of clients
in their study who left therapy without mutual agreement with their
therapists achieved reliable non-clinically significant improvement
but few made clinically significant changes. This again suggests that
these clients were far less concerned with making the latter type of
change than were their therapists. In their review of research related
to single-session therapy, discussed below, Hoyt and Talmon (2014b:
495) concluded that studies have reported a significant reduction
of distress and problem severity, as well as improvements in client
satisfaction, after a single session. This suggests that clients are sat-
isfied with what therapists would regard as non-clinically significant
improvement, but which from the clients perspective may be expe-
rienced as clinically significant.
While clients may be satisfied with what therapists define as
non-clinical improvement, apparently they can even achieve clini-
cally significant improvement in a very short period of time. Thus,

42
PRIVILEGE YOUR CLIENTS VIEWPOINTS

Barkham et al. (2006) found that half of their client sample achieved
a reliable and clinically significant change in their symptoms after
one or two therapy sessions.

Hoyt and Talmon (2014b)

Michael Hoyt and Moshe Talmon have long been at the vanguard of
making the case for the clinical utility of single-session therapy. In a
research-based overview relevant to SST, Hoyt and Talmon (2014b)
asserted the following:

1. The most common (modal) length of therapy is one visit with


2058% of general psychiatric/psychotherapy patients not
returning for better or worse after their initial visit (p. 493).1
Thus whether therapists like it or not and for better or for worse,
clients most frequently only attend for one therapy session. Per-
haps, then, we should prepare for this eventuality in the way we
approach work with new clients.
2. From clients point of view, a single session is often what is
needed (p. 493).
Between 2742 per cent of clients chose to attend for a sin-
gle session even though they could have had more (Carey
et al., 2013; Weir et al., 2008).
In several studies of SST, for approximately 60% a single
session is judged sufficient by the clients.
As it is a guiding principle that we should privilege the
client viewpoint in SST, we need to listen to what they are
saying to us with their behaviour.
3. With respect to treatment length, clients usually expect a
shorter course than do their therapists (p. 494). Whenever I am
approached by prospective clients they are keen to know how
many sessions they need to attend. They often want to attend for
very brief therapy rather than ongoing work.

43
THEORY

4. Patients have benefited by being allowed to simply walk-in or


drop-in for a single session without a scheduled appointment
when they wanted to meet with the therapist (p. 495).
5. The efficacy of SSTs is not restricted only to easy cases but
can have more far reaching effects in many areas, including
treatment of alcohol and substance abuse as well as self-harming
behaviour (p. 503).

Many therapists, when learning about single-session therapy of


whatever type, object that SST is only for so-called easy cases. As
Hoyt and Talmon (2014b) show in their review, this is not borne out
by the data.

Conclusion

The data I have presented here appear to be in accord with a funda-


mental theoretical principle of SSI-CBT: namely that when the client
viewpoint is privileged, then clients often indicate to us that they
want to be helped as quickly as possible and this book is based on the
idea that there is much to be gained by giving them what they want.
In the following chapter, I will consider the question of who can
benefit from SSI-CBT

Note

1 All page numbers in this section refer to Hoyt and Talmon (2014b).

44
WHO CAN BENEFIT FROM SSI-CBT?

7
Who can benefit from SSI-CBT?

One of the most frequently asked questions by professionals about


SSI-CBT concerns the indications for this approach. Who is best
suited to SSI-CBT? Before answering this question, let me say that
no matter how suitable a client might be for SSI-CBT, unless they
understand the nature of this approach and give their informed con-
sent to proceed then they are not a good candidate for the process.

Non-clinical problems

In my view, SSI-CBT is perhaps most applicable for people who are


experiencing non-clinical problems, by which I mean problems for
which they would not receive a formal DSM-V diagnosis. Unpack-
ing this idea further, the following would benefit from SSI-CBT:

People experiencing common, non-clinical


emotionalproblems of living (problematic forms
ofanxiety, non-clinical depression, guilt, shame,
anger, hurt, jealousy and envy)
I call these issues problems of living because they are common, but
problematic for the individual. There are some CBT therapists who
view such problems to be part of human experience and only become
problematic for the individual because of the persons response to
them. Such therapists would tend to just intervene with the persons
response to the emotion rather than try to help them with the emo-
tion itself (Flaxman et al., 2011). In SSI-CBT (WD) I would seek to
intervene at both levels since my work is guided by the REBT view
of emotions (see Dryden, 2015) which puts forward the idea that
45
THEORY

a persons response to adversity can be either problematic (nega-


tive and unhealthy based as it is on rigid and extreme beliefs) or
constructive (negative and healthy based as it is on flexible and
non-extreme beliefs).
SSI-CBT is more suited to deal with emotional problems when
these are acute rather than chronic. An acute problem may be
intensely experienced by the client, but they do not have a long his-
tory of routinely experiencing the problem across situations. This
does not necessarily mean that SSI-CBT is contraindicated when the
person has a chronic emotional problem, just that it is more likely
to be successful with acute rather than chronic problems. This state-
ment holds force no matter what issue a person brings to SSI-CBT.

Relationship issues at home and at work


Often people experience relationship problems for which they seek
help because they have become embroiled in repetitive, dysfunc-
tional cycles of interaction.1 Or they may want help and advice on
how to deal with people that they find difficult. The focus of SSI-
CBT with clients with relationship problems and issues is twofold.
First, if necessary and if deemed relevant, clients are helped to get
into a concerned, but non-disturbed frame of mind to best tackle the
issue and second, they are helped to consider and act on the idea that
as they are contributing to the problem by being involved in it, they
could help the issue by possibly acting in a different way to elicit a
more constructive response from the other. Where relevant, informa-
tion may be given about the possible psychological make-up of the
other person and to what they are likely to respond constructively
and what might aggravate the situation.

People experiencing everyday problems


of self-discipline
People who experience problems of self-discipline either do too
much of what is not good for them in the long term or do too lit-
tle of what is good for them, again from a longer-term perspective.

46
WHO CAN BENEFIT FROM SSI-CBT?

For those who want to address this and structure their life in a more
self-disciplined way, SSI-CBT can be indicated. Indeed, in my dem-
onstrations of REBT, which are in effect single sessions, the most
commonly brought issue is lack of self-discipline.

People ready to take care of business now and


whose problem is non-clinical, but amenable to
asingle-session approach
A very strong indication that SSI-CBT may be useful for someone is
when that person is ready to take care of business right now. I have
had several SSI-CBT clients who have had therapy before for the same
non-clinical problem that they have consulted me about, but without
any benefit from these previous therapies. In all cases, it transpired that
they were ready to take care of business when they came to see me, but
were not in that stage of readiness previously. Lets not forget, therefore,
that when people are ready to take care of business and are committed
to change then they are able to achieve a lot in a short period of time.
It is also the case that while the problem is non-clinical, it may
become a clinical one if not dealt with. Thus, if used at the right time,
SSI-CBT might help people deal with problems before they become
worse and require more extensive, and more expensive, therapy.

People who are stuck and need some help


to get unstuck and move on
In my view, single-session interventions are about promoting move-
ment and therefore SSI-CBT is particularly indicated when a client has
become stuck in some psychological groove. Here, you should strive to
help the person become unstuck and get on with the business of living.

People with clinical problems, but who are


ready to tackle a non-clinical problem
While SSI-CBT, in my view, is best indicated for those seeking help
with non-clinical problems, people with clinical problems can also

47
THEORY

be helped with this approach to single-session work with their non-


clinical problems when their clinical problems do not interfere with
the resolution of their non-clinical problems.

Martha had borderline personality disorder, but wanted help


with her public speaking anxiety to help prepare her for a
presentation that she had to give for a job interview. Her regular
therapist was away so she sought, with permission, help from a
SSI-CBT therapist who worked with her in one session to deal
with her specific anxiety issue.

People with life dilemmas and quandaries


A dilemma occurs when a person is faced with a choice between two
equally undesirable alternatives, while a quandary involves a state
of uncertainty about a situation requiring the person to take some
action. It is likely that the client, in either of these states, has spoken
to a number of people, but has not resolved the situation.

People requiring to make an important


imminentdecision
Related to the above is the situation where a client wants to talk through
the factors surrounding a decision that is imminent and wants to do so
with someone not invested in the outcome of that decision. They are
not experiencing a dilemma or a quandary, but are seeking an opportu-
nity to discuss the situation with someone who they know will not give
them unwanted advice. SSI-CBT will give them such a forum.

People who are finding it difficult to adjust


to life in some way
Single-session work is particularly useful for those clients who are
finding it difficult to adjust to life in some way after making some kind
of transition. Helping students to adjust to university is a good example
of this work (Cowley and Groves, 2016). SSI-CBT, with its emphasis

48
WHO CAN BENEFIT FROM SSI-CBT?

on helping clients question the meaning that they have placed on what
they expect of themselves and the environment to which they are
struggling to adjust, is particularly useful in this context.

People with meta-emotional problems


I mentioned above that Acceptance and Commitment Therapists
take the position that it is not our experience of negative emotions
that signifies our problems rather it is the way that we grapple
with the existence of these problems. For ACT therapists and other
CBT practitioners who take the view that clients need to be helped
to mindfully accept their negative emotions and the thoughts that
accompany them rather than to change these experiences, working
at this meta-level is the main thrust of how they practise SSI-CBT.
For CBT therapists who take the different view that the thoughts
and beliefs that underpin psychological stress can be the legitimate
target of change, dealing with meta-emotional problems will occur
under two conditions. First, when the existence of these meta-level
or secondary emotional problems obstruct the work to be done on the
primary problem (usually nominated by clients as the major reason
why they have sought help) and second, when the meta-emotional
problem turns out to be the clients major problem.

Fred sought SSI-CBT for his angry feelings towards authority


figures who misused their power. He was pre-occupied with
these feelings and tried hard to suppress them. As it transpired,
Freds major problem was his meta-emotional problem of
shame about his angry feelings, for, as he came to see, if he did
not feel ashamed of his anger he would not be pre-occupied
with it or try to suppress it.

People who view therapy as providing


intermittenthelp across the life cycle
Some people see consulting therapists somewhat like consulting their
GP. They will consult them both when they have a problem and will

49
THEORY

stop going when the problem has been addressed to their satisfaction.
They are happy to proceed in this manner across the life cycle. Given
this preference, this group of clients are suitable for SSI-CBT.

People who require prompt and focused


crisismanagement
While John F. Kennedy was factually incorrect when he said that in
Chinese the word for crisis is composed of two characters: one mean-
ing danger, the other opportunity, it is the case that when people are in
crisis, they are in a highly distressed state, but there is also the oppor-
tunity to help them deal quickly with the crisis assuming their level of
distress can be managed. If so, SSI-CBT is suitable for clients in crisis.

Clinical problems

I stated earlier that SSI-CBT is best suited for emotional problems


that are non-clinical in nature. However, we have also seen with the
case of Vera, which I discussed in Chapter 5 and who suffered from
specific phobia, that under certain circumstances people with clini-
cal problems can benefit from SSI-CBT. These circumstances are
that the problems in question have been shown to be amenable to a
single-session approach and that the people who experience these
problems are ready to take care of business and ready to do what they
need to do to address these problems effectively. There are two major
examples in the literature on CBT being used with clinical problems
within a single-session format. I am referring here to sts intensive
single-session approach with phobias (Davis III et al., 2012) and
Reinecke et al.s (2013) single-session approach to panic disorder.
It is important to note that both approaches involve actual exposure.

Coaching

So far I have discussed the indications of SSI-CBT for clients who


have problems for which they wish to have help, whether these be

50
WHO CAN BENEFIT FROM SSI-CBT?

non-clinical or clinical in nature. In addition, SSI-CBT can be used


with people seeking help and advice concerning how to get more out
of themselves, their work, their relationships and their life in general.
These people are doing OK in the various aspects of their lives and/
or in their lives in general, but have the sense that they are not fulfill-
ing their potential. The focus of this work is usually referred to as
coaching whether this label is used to describe the work formally
or informally.
While coaching is usually a longer-term process, it can be used
within a single-session format. This is the case when the person
wants a session with a coach to kick-start a process that they want to
do on their own or they have a specific objective that they think that
can achieve at the end of a single focussed session.
My experience of using SSI-CBT in a coaching context is
that the work is largely focused on helping people identify and
deal with obstacles to setting or working towards coaching-type
objectives.

Prevention

Human beings are generally better at problem solving than they are
at problem preventing. When asked to think about prevention they
can agree that it is a good idea at the time, but they wont act on this
agreement because they are not committed to doing so. However,
there are times such as when people are given a warning by a health
professional that they need to take action to prevent the development
of a problem that people will seek prophylactic help and much can
be achieved with SSI-CBT.

Harry was given an annual physical by his company doctor


who warned him that if he did not begin to take exercise that
he was likely to develop health problems. Harry sensed that he
needed a bit of psychological help to adjust to the news and to
deal with his reluctance to act on the advice, both issues were
successfully dealt with in SSI-CBT.

51
THEORY

Psychoeducation

I define psychoeducation as the provision of information and experi-


ences designed to help a person learn more about a psychological
problem, process or treatment (see also Lukens and McFarlane,
2004). There are a number of situations that fall within this purview
where SSI-CBT can be indicated.

People who are open to therapy, but want to try


itfirst before committing themselves
Before they commit themselves to a course of therapy some people
want to try it first. My own view is that this a perfectly reasonable
request and I usually reply that I am happy to offer them a session as
long as they come with a specific issue that they want help with and a
goal that they want to achieve. Then, we can both see how far we can
get in dealing with the issue and in doing so they can gain a sense of
what the process is like and make a decision to commit themselves
to more therapy if needed.

People seeking advice on how CBT would tackle


their own problem
I sometimes get phone-calls from people asking me how CBT
might tackle a problem or problems for which they want help.
They may have been advised to seek CBT and not know much
about it or they may be gathering information about how differ-
ent therapies might endeavour to help them. Again, I consider
this to be a legitimate strategy and respond that I am happy to
offer them a session so that they can learn first-hand how CBT
might tackle the problem and, I recommend that they come to
such a session with a specific example of the problem and a goal
in mind that they would like to achieve with respect to the spe-
cific example.

52
WHO CAN BENEFIT FROM SSI-CBT?

People who are reluctant about seeking therapy


andare only prepared to commit to one session
Some people are reluctant about seeking therapy. In such situations
if they agree to consult a therapist it is normally at someone elses
behest and they promise to go but for only one session. Again, I
am happy to see them for one session, but recognize that its very
likely that they will be in a very different stage of change than, for
example, the person who wants to see what CBT has to offer them.
With reluctant clients, the pre-session telephone contact is crucial in
determining the course of the face-to-face session.

Therapy trainees who want to find out what it is


liketo have therapy from a different perspective
Trainees in psychotherapy are often expected to learn about therapy
approaches other than the one in which they are primarily being
trained. While they can read about these other approaches it is diffi-
cult for them to experience the therapy from the inside. I sometimes
receive requests from non-CBT trainees who wish to experience
CBT and I am happy to offer them a single session so long as they
can bring a real specific problem that they wish to discuss and have
a sense of what they want to achieve.

Other contexts

SSI-CBT is also indicated in other contexts that dont necessarily fit


into the headings provided above.

Clients in therapy who are seeking a second


opinion(or their therapists are)
It is not uncommon in medical practice for patients to seek a sec-
ond opinion and sometimes their doctors are the ones to initiate this,

53
THEORY

particularly if the patients are not making expected progress and


they, the doctors, are not clear about the reasons for this. Although
this phenomenon is less common in the therapeutic professions, it
does occur and SSI-CBT can be offered in response to second opin-
ion requests.
If a therapist asks me to offer a second opinion, once I have
checked that this is acceptable to the client, I state to both that I will
give my opinion at the end of the session verbally to the client
and over the phone to the therapist, but basically my feedback will
be the same. Having been briefed by the therapist, and having had
a brief telephone call with the client, I will normally send the cli-
ent an email with a list of questions for them to consider before we
have the single face-to-face session. These questions will be based
mainly on the therapists briefing, but also by my brief call with
the client.
If the client initiates the second opinion request, I will normally
only do so if the therapist has been informed as I consider this to be a
matter of professional etiquette. Once this is given, I will also email
the client a list of questions to prepare before our face-to-face single
session, but the questions are likely to be more general than they
would be if I was briefed by the therapist. At the end of the session, I
will offer the client my opinion, but it is very unlikely that I will have
any direct contact with the therapist unless both client and therapist
request this after the session has taken place.

Clients in ongoing therapy who want brief help


witha problem with which their therapist cant
orwont help them
When some people are in ongoing therapy with non-CBT therapists
it sometimes happens that they develop a specific problem or want
to discuss a specific problem that their therapist does not feel able to
deal with or does not want to help them with because doing so will
derail the work that they are doing with these clients in the course of
therapy. As clients do want help with these specific problems their
therapist recommends that they seek CBT for short-term help with

54
WHO CAN BENEFIT FROM SSI-CBT?

these problems and sometimes, given other considerations already


discussed, this short-work can be in the form of SSI-CBT.

People who are only in town for a short period


andneed some help in that town
Sometimes, people from another part of the country or even from
a different country may wish to seek help from a CBT practitioner
while they are in the same town as that practitioner. This naturally
lends itself to a single-session therapy format, especially if the client
meets some or most of the inclusion criteria that I have already dis-
cussed. If the client is in ongoing therapy with another practitioner,
whether it be a CBT therapist or a non-CBT therapist, it is important
that the client has their therapists agreement for the session.

People who volunteer for a demonstration session


before an audience
I personally do a great many demonstrations of CBT in front of an
audience. I ask for volunteers with genuine problems who wish to
discuss them and to seek some kind of resolution before the audience
poses questions to both myself and to the volunteer client. I should
stress that I have not met the person before and know nothing about
what they are going to discuss with me. This is effectively single-
session therapy and generally the session lasts for about 30 minutes.

People who volunteer for a videotaped


demonstration session
A similar situation occurs when a person volunteers to be a client in a
videotaped demonstration session of CBT. Again the main inclusion
criterion for this is that the person needs to discuss a genuine prob-
lem for which they seek a resolution. This situation differs from live
demonstration single-session CBT in that the audience is not present,
but one step removed in that they will be watching the session after
it has been published. Also videotaped demonstration single sessions

55
THEORY

tend to be longer than live demonstration single sessions, given the


fact that they are published and marketed as a full therapy session.

People who are suitable for short-term CBT


may also be suitable for SSI-CBT

Safran et al. (1993) specified a number of criteria which detailed


which patients were suitable for short-term cognitive behaviour
therapy. In this chapter, I will list their suggestions and while I have
already discussed some of these criteria in this chapter, it is worth
looking at Safran et al.s list in its entirety here. Thus Safran et al.s
guidelines for suitability for short-term CBT suggest the following
indications for SSI-CBT:

The person demonstrates facility in accessing thinking pro-


cesses in relation to their target problem.
The person exhibits facility in being aware of emotions and
being able to differentiate among them.
The person accepts personal responsibility for change.
The person readily agrees that there is a relationship between
thinking and feeling.
It is likely that the person will find it easy to develop an alliance
with the therapist.
The person has had sustained trusting relationships and is able
to stay in interpersonal contact in conflict situations.
The persons nominated target problem is acute not chronic.
The person is willing and ready to discuss troublesome issues.
The person is able to focus on the specific target problem nomi-
nated for change.
The person does believe that therapy is likely to be helpful, both
therapy in general and CBT in particular.

As I will discuss more fully in Part 2 of this book, one of the major
purposes of the pre-session telephone contact is for the therapist to
gauge the persons suitability for SSI-CBT and it is very useful to

56
WHO CAN BENEFIT FROM SSI-CBT?

have both Safran et al.s criteria and the others that I have listed to
hand in the form of a checklist so that the items on the list can suggest
useful lines of enquiry in the phone interview.
Having discussed fully the inclusion criteria for SSI-CBT, let me
now consider some of the exclusion criteria.

Note

1 This book is devoted to single-session therapy with individuals and there-


fore I discuss helping individuals (rather than couples, for example) with
their relationship problems. For coverage of SST with couples and fami-
lies see Hoyt and Talmon (2014a).

57
CONTRAINDICATIONS FOR SSI-CBT

8
Contraindications for SSI-CBT

Some people in the SST world hold the position that there are no
contraindications for single-session therapy, arguing that even the
most disturbed person can gain something from a single session and
pointing out that all people signing up for SST can have more ses-
sions, if they so request. My view is different. I think that if there
are indications for SSI-CBT, it follows that there are contraindica-
tions as well and in this chapter, I will discuss some of the major
contraindications.

People who find it difficult to connect with


or trust a therapist quickly

In order to benefit from SSI-CBT, the person needs to be able to


open up to their therapist quickly and disclose deeply about their
problem/issue. Some clients would find this difficult and others have
trust issues in the sense that they would only be prepared to express
themselves fully with their therapist once they trust him or her. For
such clients, SSI-CBT is not indicated.

People who request ongoing therapy

When people come to therapy some of them consider that, given


their problems for which they are seeking help, they require ongoing
therapy. Given this view and preference, these clients are not good
candidates for SSI-CBT because they are clear about what they want
and what they think will be helpful for them.

59
THEORY

People who dont want CBT of any description

I once ran a group therapy programme in a private hospital that was


based on CBT. While this programme was largely popular, occa-
sionally clients refused to join the programme because they held
negative feelings about CBT, which they were not willing to look
at. One person even said that he would rather kill himself than join
a CBT group! While holding negative feelings about CBT may not
be a contraindication for SST, it is a contraindication for SSI-CBT.

People who need ongoing therapy

Sometimes people request SSI-CBT when it turns out that they need
to be seen in ongoing therapy. For me here are some of the signs
where this is the case.

The person is seeking help for a problem that is chronic and too
complicated to be dealt with in one session even if the person
has a strong committed reason to change.
The person is seeking help for several problems that are too
complex to be dealt with within the SSI-CBT and there is no
clear linking theme among them. If there is a clear linking theme
and this can be the focus for a single session then this may indi-
cate suitability for SSI-CBT.
The clients goals are too ambitious to be achieved within the
SSI-CBT format and the person will not be satisfied with what
SSI-CBT might more realistically allow them to achieve

People who have vague complaints and


cant be specific

SSI-CBT works much better with clients who have clear-cut prob-
lems or issues and can specify what these are. However, when
people are very vague and find it difficult to be specific about their

60
CONTRAINDICATIONS FOR SSI-CBT

problems/issues, they will require more time to be helped; first to


specify what the problems/issues are and second, to deal with these
now specified problems/issues. This is most likely to become appar-
ent in the first phone call or more likely in the pre-session phone
call. The same is also true concerning goals. When clients have very
vague or woolly goals and cant be quickly helped to specify them,
then they may not be suitable for SSI-CBT.

People who are likely to feel abandoned


by the therapist

As I have already mentioned and will discuss in detail in Part 2 of


this book, SSI-CBT has four points of contact between therapist and
client: (a) the first contact; (b) the pre-session telephone contact;
(c) the face-to-face session; (d) the follow-up session. I mentioned
earlier that SSI-CBT is not indicated for people who would find it
difficult to make a quick connection with their therapist and/or trust
him or her quickly. Similarly, SSI-CBT may not be indicated for
those who would find the sudden ending of the main part of the pro-
cess (i.e. after the face-to-face session) very difficult and may feel
abandoned by the therapist. For others, however, knowing that there
will be a follow-up contact approximately three months after the
face-to-face session is sufficient to prevent this sense of abandon-
ment being experienced. This needs to be taken up with the person
during the pre-session telephone conversation.

People who are not suitable for short-term CBT are


generally not suitable for SSI-CBT

In the previous chapter, I listed Safran et al.s (1993) specified criteria


for which patients were suitable for short-term cognitive behaviour
therapy. In this chapter, I will list their suggestions concerning which
patients are unsuitable for short-term CBT. While I have discussed
some of these criteria already in this chapter, it is worth looking at

61
THEORY

them in their entirety here. Thus Safran et al.s guidelines for unsuit-
ability for short-term CBT suggest the following contraindications
for SSI-CBT:

The person has difficulty in accessing thinking processes


The person exhibits great difficulty in being aware of emotions
and being able to differentiate among them
The person does not take personal responsibility for change
The person does not agree that there is a relationship between
thinking and feeling
It is likely that the person will have great difficulty developing
an alliance with the therapist
The person has few, if any, sustained relationships, and those
that they do have are marked with mistrust and ambivalence
With respect to the persons nominated target problem, they
exhibit a very chronic history
The person is avoidant of discussing troublesome issues
The person is unable to focus on the specific target problem
nominated for change
The person does not believe that therapy is likely to be helpful,
either therapy in general or CBT in particular.

As I mentioned at the end of the last chapter, it is useful to have


at hand a checklist of inclusion and exclusion criteria for SSI-CBT
when conducting the pre-session telephone interview and to use
these to frame your questions during the call.
In the next chapter, I will discuss the assumption of SSI-CBT that
a focus on both problems and goals is important.

62
FOCUS ON BOTH PROBLEMS AND GOALS

9
A focus on both problems and goals
isimportant in SSI-CBT
SSI-CBT is best seen as a problem-focused, goal-oriented approach
to single-session therapy. As such it differs from single-session ther-
apy which is based on solution-focused lines, for example, which
steers clients away from their problems and just orients them towards
solutions or preferred futures.

Focus on problems

When considering problems in SSI-CBT, you should be mindful of


the single-session nature of the work. At the forefront of your mind
should be the following question: What type of problem can I help
my client realistically deal with within the context of single-session
therapy? In my experience this question can be shared with your
client with the purpose of you choosing together a client problem
that can be realistically dealt with within the context of this particu-
lar therapeutic frame. When a suitable problem has been identified
this is known as the target problem. When the target problem is
assessed, if possible, you need to understand both a specific example
of the target problem and its general nature. At this point, if you
focus on too specific an example of the problem then your client will
not be helped to generalize learning from the example. Similarly, if
you focus on the problem at a too general nature, then your client
will not be helped to engage emotionally in problem assessment and
exploration.

63
THEORY

My suggestion is that, if possible, it is best to identify the general


target problem and a specific example of it. Here is an illustration of
what I mean:

General target problem: I get walked over by people close to me.


Specific example: This happens specifically with my aunt
whenever I visit her.

AC-based problem focus


Once a target problem has been selected and put in its general and
specific context, then you need to engage with the client in the
process of understanding the nature of the problem (i.e. the clients
emotional and/or behavioural response) and to which adversity
the person is responding. I mentioned in Chapter 3, most CBT
therapists employ an ABC framework when assessing their cli-
ents problems. In the ABC framework, A stands for adversity or
negative activating event, B stands for belief or thinking and C
stands for the persons emotional and behavioural response to the
adversity. Remember also from Chapter 3 that the persons emo-
tional problem (at C) suggests what type of adversity they are
facing or think they are facing. When as a SSI-CBT therapist you
adopt a problem focus, then you are effectively utilizing the A and
C components of this framework. You will focus on the cognitive,
thinking and/or belief component of the ABC framework a bit later
in the process. Effective SSI-CBT therapists learn which adversi-
ties tend to go with which emotions and use this as a guide when
focusing on the clients target problem as in the following dialogue
(see Chapter 4).

Client: I just get trod on time and again because Im just


scared of upsetting my aunt if I stand up to her.
Therapist: Whats threatening to you about upsetting her?

[Here the therapist is using their knowledge that when


a person is scared it is because they are inferring the

64
FOCUS ON BOTH PROBLEMS AND GOALS

presence of something threatening to their personal


domain.]

Client: Well, if I upset her then I will torment myself.


Therapist: With guilt?
Client: Absolutely.

[Again the therapist is using their knowledge concern-


ing which emotion is suggested when a client finds
upsetting somebodys feelings a problem and uses this
knowledge to guide their intervention.]

It is a moot point concerning how formal you need to be in using


the AC components of the ABC framework. This is partly a stylistic
question for you, as therapist, but it also concerns how valuable the
client would find using this framework formally.
If the above therapist had utilized the AC components of the ABC
framework format formally with the above clients target problem, it
would have looked like this:

A: Upsetting my aunt
B: Not known yet
C: (emotional): Guilt
(behavioural): Not standing up for herself

Note that the B section is not yet known yet. This section is
assessed once the target problem and the goal with respect to that
target problem have been identified and agreed.

Focus on goals

Once the nature of the clients target problem has been understood,
the next step is to help the client to set goals with respect to that
target problem. This is more complex than it appears at first sight. In
particular, when asked about their goal, clients will usually respond

65
THEORY

with either an absence of a negative emotion or a positive way of


behaving, but usually they would not make reference to the adversity
that appears in their problem.

Therapist: So you get trod on by people like your aunt because


you would feel very guilty about hurting her feelings
if you were to stand up to her. Is that right?
Client: Pretty much.
Therapist: What would you like to achieve in discussing this
problem with me?
Client: I would like to stand up for myself.

[Here the client has nominated a positive behaviour


with respect to her goal. However, note that she has
not specified a goal concerning how to deal with the
situation where she upsets her aunt. At the moment
she would feel guilty about doing so and to avoid feel-
ing guilt she backs down. So the therapist has to do
something tricky here. To work with the clients stated
goal to stand up for herself and to help her set
a goal concerning upsetting her aunts (and others)
feelings.]

Thus, it is important to help clients set goals in the face of adver-


sity before helping them to reach their stated goals when these goals
make no reference to the adversity in question. In the above example,
the therapist proceeds thus:

Therapist: OK, so you would like to stand up for yourself and


I will certainly help you to do that. However, given
that you feel guilty about the prospect of upsetting
people like your aunt when you do is stand up for
yourself, do you think that it would be wise if I first
helped you to deal better emotionally about upsetting
people?
Client: Yes, that makes sense.

66
FOCUS ON BOTH PROBLEMS AND GOALS

Therapist: So, I need to help you to experience an emotion which


is negative given that for you upsetting people is neg-
ative, but one that does not stop you from standing up
for yourself.
Client: Couldnt you help me to stand up myself so that I
dont upset people?

[This is quite common. The client wants to find a way


of achieving their goal without facing the relevant
adversity. Sadly, this is not possible as no matter how
well they stand up for themself the other person may
be upset with them.]

Therapist: Well, I will certainly try to help you to stand up for your-
self in a way that minimizes the chance that the other
person will become upset with you, but do you think
its possible for you to eradicate that as a possibility?
Client: I guess not.
Therapist: So would it make sense for me to help you to deal
with the possibility that the other person will become
upset with you but to do so without that stopping you
from standing up for yourself if that happens?
Client: Yes.
Therapist: So, as I said before I need to help you to experience
an emotion which is negative given that for you upset-
ting people is negative, but one that does not stop you
from standing up for yourself. Right?
Client: Right.
Therapist: So your feelings of guilt about upsetting people like
your aunt are stopping you from standing up for your-
self. What emotion about upsetting them would be
negative in tone, but would not stop you from assert-
ing yourself?
Client: Being sorry, but not guilty.
Therapist: Excellent, so shall I help you do that in the first instance?
Client: Yes, please, if you can.

67
THEORY

AC-based goal focus


I mentioned above that AC components of the ABC framework drive
the therapists focus on the clients target problem. They also drive the
therapists focus on the clients goal with respect to that target prob-
lem. In doing so, the therapist ensures that the client sets a goal with
respect to the adversity at A rather than bypassing the A. The ther-
apist, in the above example, shows how to respond when the client
tries to factor out the adversity in their goal-setting.
If the above therapist had utilized the AC components of the ABC
framework format formally with the above clients goal it would
have looked like this:

A: Upsetting my aunt
B: Not known yet
C: (emotional): Sorry rather than guilt
(behavioural): Standing up for herself

Note again that the B section is not yet known yet. As before this
section is assessed once the target problem and the goal with respect
to that target problem have been identified and agreed.
In the next chapter, I will discuss the role of assessment and for-
mulation in SSI-CBT.

68
CARRY OUT A FULL ASSESSMENT

10
Carry out a full assessment and do as
muchcase formulation as you can in
thetimeavailable
In the previous chapter, I discussed how as an SSI-CBT therapist you
can use the AC components of the ABC framework introduced in
Chapter 4 to identify your clients target problem and their goal with
respect to the target problem. In this chapter, I will discuss the role of
assessment and case formulation in SSI-CBT. In my view, you need
to do a comprehensive assessment of the clients target problem and
as much case formulation (meaning understanding the mechanisms
which account for the clients problems from a broader perspective)
as you can in the time that you have at your disposal.
It is important to understand assessment and case formulation in the
context of other SSI-CBT tasks. Once you and your client have agreed
that SSI-CBT is suitable for the latter, you need to do the following:
(1) identify and agree on the clients target problem; (2) identify and
agree on the clients goal with respect to this problem; (3) assess the
problem and formulate the mechanisms that account for the continu-
ing existence of the problem; (4) identify a central focus that can be
target for change; (5) work to effect change in this central focus; and
(6) give the client an opportunity to rehearse change in the session in
some meaningful way. Throughout this process you need to ally the
clients strengths together with what you have to offer the client. In
order to do all this, you have about 1.5 hours at your disposal, which is
the time that is allocated to the pre-session telephone contact and the
face-to-face session. It can be seen, therefore, that when it comes to
assessment and formulation, you need to decide what to include and
what to leave out since you do not have the time to be all inclusive in
SSI-CBT. These decisions will vary from client to client.

69
THEORY

Assessment of B in the ABC framework

You will recall that in the previous chapter, I showed how you can
use the A and C components of the ABC framework to help you
and your client identify and understand both the nature of the clients
target problem and their goal with respect to this problem. After this
has been done, you are ready to assess the clients cognitions at B.
Different CBT therapists will have different ideas about what cog-
nitive activity to focus on when carrying out the assessment of B. For
example, those following the ideas of Aaron T. Beck will assess the
presence of negative automatic thoughts (NATs), intermediate beliefs
often expressed in the form if-then and core schemas. Normally, in
ongoing CBT of this type, the therapist moves quite slowly from the
more surface level of NATs, to the intermediate level and thence to the
core schemas. Such slow-paced assessment is not possible in SSI-CBT
so that Beckian CBT therapists need to make a judgment call concern-
ing what to focus on and what to omit when practising SSI-CBT.
Those therapists who practise Acceptance and Commitment
Therapy (ACT) will focus on the thoughts that their clients struggle
with. In this form of CBT, it is the struggle that clients have with
their thinking rather than the thinking itself which is regarded as
problematic. Thus, ACT therapists will tend to identify cognitions
not with the view of changing them but with a view of then assess-
ing the struggle mechanisms that clients themselves employ in their
attempts to change or eliminate these cognitions.
My own approach to single-session therapy which I am calling
here SSI-CBT (WD), is, as I have said, based more on the ideas of
Albert Ellis who developed Rational Emotive Behaviour Therapy
(REBT). In this approach to CBT, it is hypothesized that emo-
tional and behavioural problems are underpinned by a set of rigid
and extreme beliefs and I am guided by this theoretical point while
assessing cognitions at B.
Having pointed out the differences among some of the major CBT
approaches, it is important to note that when you are practising SSI-
CBT in general, and when you are assessing cognition, in particular,
it is important that you develop a flexible and pluralistic mindset

70
CARRY OUT A FULL ASSESSMENT

and approach. In my case, while my own thinking is influenced


by the view that clients emotional and behavioural problems are
underpinned by rigid and extreme beliefs, if a particular client does
not accept this view and resonates more, for example, with the ACT
position that it is their struggle with their dysfunctional cognitions
that is at the root of their target problem then I will proceed on this
basis. I would just not have the time in SSI-CBT to devote to discuss-
ing the merits and de-merits of both positions. In addition, my view
is that in SSI-CBT, and I suspect in other approaches to SST too,
quickly developing and maintaining an effective working alliance is
a key idea, which in this context means going along with the clients
perspective on the relationship between cognition and the persons
target problem (see Chapters 2 and 6).

Position on case formulation

A case formulation approach to CBT differs from assessment in CBT


in that in the former a set of mechanisms are put forward to account
for the problems that the client is seeking help with while in the latter,
each problem is understood on its own merits. In ongoing CBT, the
therapist may wish to do a full case formulation before intervening.
In SSI-CBT, there is insufficient time to do this. However, in SSI-
CBT, the therapist does have to work with both the specific and the
general. Too much emphasis on the specific may mean that the thera-
pist may not discover the existence of more general mechanisms that
may affect the maintenance of the specific problem if not dealt with.
Too much emphasis on the general may mean that the therapist may
not help the client sufficiently with their target problem.
My own view is that in SSI-CBT when I have done an assessment
of the clients target problem and I need to understand this problem
from a wider perspective, meaning that I am carrying out some case
formulation tasks, I will enquire about some of the following:

how general the clients difficulty is with the adversity at A


so that I can suggest ways in which the client can generalize

71
THEORY

their learning from the adversity in the target problem to similar


adversities;
ways in which the client tries to avoid the problem;
ways in which the client acts to keep themself safe;
ways in which the client attempts to eliminate experience;
ways in which the client may try to make themselves feel better;
usage of alcohol, food and drink;
the clients reaction to their target problem;
ways in which the client may over-compensate for having the
problem;
any advantages the client sees to having the problem;
how the person involves other people in their target problem;
what the person may lose by achieving their goal.

However much formulation you can do will, as I have said, vary


from client to client and how much time you have at your disposal.
However, as I said earlier, you cannot do a full case formulation
before you intervene in SSI-CBT. There is insufficient time to do
this.
In the next chapter, I will discuss the assumption that you can
identify and work with a central mechanism in SSI-CBT.

72
IDENTIFY AND DEAL WITH A CENTRAL MECHANISM

11
In SSI-CBT it is possible to help clients
identify and deal with a central
mechanismresponsible for the existence
oftheir problems
One of the challenges of single-session therapy is for you to ensure
that you help your client take away with them something that is
meaningful in the sense of being able to address effectively their
target problem and move towards their goal. However, you need to
be concerned that what the client takes away with them has durable
results. The chances of doing this are enhanced when the client is
helped to identify and deal with what I call a central mechanism
that is responsible for the presence of their target problem. Given
the emphasis in SSI-CBT on cognitive and behavioural factors, this
central mechanism is likely to be cognitive in nature and have behav-
ioural referents in that it explains why the client acts in the way they
do when they are in problem mode. There also needs to be some
plausible alternative in cognitive meaning for the client, which itself
needs to suggest alternative and more constructive behaviours that
are goal-oriented. Here is an example from my own practice of SSI-
CBT (WD).

Barry sought SSI-CBT from me for help with his exam anxiety.
What he feared most about examinations was not being able to
think clearly and eventually going blank. He also had a similar
fear in social situations and would often avoid people with
whom he thought that this would happen. These people would
generally be women to whom he was attracted. Although he
nominated his exam anxiety as his target problem, the generic

73
THEORY

nature of his threat i.e. his mind going blank suggested a central
mechanism and I thought that if I could promote a shift in the
way he thought about his mind going blank in the exam arena,
I perhaps could help him to generalize this change to the social
arena. The central mechanism responsible for his problem in
both arenas was that his mind going blank meant to him that
he was an idiot and this had to be hidden from himself and
others. In the exam arena this involved him over-preparing and
in the social arena it involved him avoiding talking to attractive
women. As the central mechanism, i.e. I am an idiot, suggested
alternative meaning systems, this self-evaluation became the
focus for examination and change in the face-to-face session
and alternative behaviours suggested by the new meaning
system (in Barrys case, going blank is human and I dont have
to hide this) became apparent.

In order to give oneself the best chance of identifying and


thence dealing with a central mechanism, you need to be able
to focus on the central core of the clients target problem and
help the client do the same. You may need to interrupt your cli-
ent to help them stay focused and I recommend that you explain
in advance that you may have to do this and seek your clients
permission to do so.

The central mechanism in SSI-CBT (WD): an example


oftheory-driven therapy and open-mindedness

In this section, I will show how I make use of REBT theory in help-
ing clients to identify and deal with a central mechanism in my own
approach to SSI-CBT that I call SSI-CBT (WD). In my view, REBT
theory lends itself to single-session therapy as it advances the idea
that people bring their desires to adversities and when they keep these
desires flexible (known as a flexible belief ), they handle these adver-
sities constructively and when they make these desires rigid (known

74
IDENTIFY AND DEAL WITH A CENTRAL MECHANISM

as a rigid belief ), they disturb themselves and thus dont handle the
adversities well. My therapeutic task, then, is to encourage my client
to acknowledge their desire with respect to the adversity and to keep
it flexible.
REBT theory additionally argues that if the person holds a
flexible belief about an adversity then they will also tend to hold
one or more of three non-extreme beliefs which underpin their
constructive handling of the adversity: a non-awfulizing belief
(This adversity is bad, but not awful), a discomfort tolerance
belief (This adversity is a struggle to tolerate but I can tolerate it
and it is worth it to me to do so) and an acceptance belief (Its
bad that this adversity happened, but I/you/the world are not bad,
but a complex mixture of good, bad and neutral and I can accept
myself/you/the world accordingly). If the person holds a rigid
belief then they will also tend to hold one or more of three extreme
beliefs which underpin their unconstructive response to the adver-
sity: an awfulizing belief (This adversity is bad, and therefore
it is awful), a discomfort intolerance belief (This adversity is a
struggle to tolerate and therefore I cant tolerate it) and a depre-
ciation belief (Its bad that this adversity happened and therefore
I/you/the world is bad). My therapeutic task here is to help my
client acknowledge evaluation of badness, struggle and the nega-
tive part evaluation respectively where relevant and to keep these
non-extreme.
The final part of REBT theory that is relevant here and one
that has been mentioned in passing above is that when a person
holds a set of flexible and non-extreme beliefs about adversity
then they will tend to experience healthy negative emotions about
it, act constructively towards it and subsequently think in bal-
anced ways. Conversely, when a person holds a set of rigid and
extreme beliefs about the same adversity then they will tend to
experience unhealthy negative emotions about it, act unconstruc-
tively towards it and subsequently think in highly distorted ways
about it.
This theory can be summarized graphically in Figure 11.1.

75
THEORY

Adversity

Desire

Kept flexible [therapeutic task] Made rigid

Flexible belief Rigid belief

Evaluation of badness of the adversity

Awfulness negated [therapeutic task] Awfulness asserted

Non-awfulizing belief Awfulizing belief

Struggle acknowledged

Discomfort tolerance asserted [therapeutic task] Discomfort intolerance asserted


Discomfort tolerance belief Discomfort intolerance belief
Negative part evaluation

Whole evaluation negated and accepted Whole evaluation asserted and depreciated
[therapeutic task]

Acceptance belief Depreciation Belief

Emotional, behavioural and thinking responses

Healthy negative emotion Unhealthy negative emotion


Constructive behaviour Unconstructive behaviour
Subsequent thinking is balanced Subsequent thinking is highly distorted
and skewed to the negative

Figure 11.1 REBTs theory used to help clients identify and deal with their
central mechanisms

Sarah was a student who was procrastinating on a number


of university projects and sought SSI-CBT for this issue. Her
goal was, as she put it, to overcome her procrastination and
get down to work because doing so would help her to get good
grades and a good degree. I encouraged Sarah to focus on her
central mechanism by asking her what conditions she believed
she needed before working on these projects. She replied that

76
IDENTIFY AND DEAL WITH A CENTRAL MECHANISM

before she got down to work she needed (a) to feel motivated
and (b) to know that she would get a good grade. If she had
that motivation and was confident that she would get at least a
B then she would get down to work. Sarahs response to this
situation was to try to psych herself up and convince herself
that she would get a good grade, strategies that worked only
in the very short term.
The ABC assessment that we developed was as follows:
A = Lack of motivation, not certain that I will get a good
grade
B = I must feel motivated and know that I will get a good
grade
C = Procrastination
My therapeutic task was to help Sarah grasp the point that her
desires for pre-work motivation and outcome confidence were
perfectly fine and that if she kept her desires for these conditions
flexible then she would start work in their absence because she
had good reason to. Once she accepted this, we looked for a
reminder of this central mechanism that would be inspirational
and prompt action. Sarahs goal-oriented ABC was as follows:

A = Lack of motivation, not certain that I will get a good


grade
B = It would be good if I felt motivated to do my work and if
I knew that I will get a good grade, but I do not need to
have my desires met
C = Start working

When helping clients to identify with a central mechanism in


SSI-CBT, it is important to be guided by theory, for as Kurt Lewin
(1951) famously noted: There is nothing so practical as a good the-
ory. Thus, I have outlined how REBT theory guides my practice in
helping clients in SSI-CBT (WD) to identify and deal with a central
mechanism. However, there is another equally important principle
that guides my practice in single-session work and it is this: If a client

77
THEORY

does not find REBT theory helpful, then I will not continue to employ
it. Rather, I will be open-minded and be guided by the clients own
view of the central mechanism and will make use of this instead. In
this way, my open-mindedness will preserve the working alliance
between myself and my client in the views domain (see Chapter 2).
In the next chapter, I will consider the assumption that is made
in SSI-CBT that the persons first response to an adversity is not as
important as how they respond subsequently.

78
SUBSEQUENT RESPONSES

12
The persons subsequent responses
to theirfirst response are often more
importantthan the first response itself
When people come for therapy, whether it be single-session therapy
or ongoing therapy, they often want to eliminate their problems and
the dysfunctional processes that are involved in these problems. As
practitioners of CBT approaches that are based on the principles of
acceptance and mindfulness often point out, it is our responses to
these processes that are the problem rather than the processes them-
selves. They would agree with the notion, therefore, that it is the
persons subsequent responses to their first response that are more
important than their first response itself in determining whether or
not they have problems.

Subsequent responses to the first response:


1.Problematic cognitions

Lets take the example of a person who fails his (in this case) driv-
ing test and gets depressed and reports having the thought/belief,
Im a failure. This thought/belief may be regarded as the persons
first response to the adversity of failing the test. Acceptance and
mindfulness-based therapists would encourage the person to notice
and accept this thought and its associated feeling and get on with the
business of value-based living. This noticing, accepting and taking
action would be regarded as their subsequent responses to the first
response, Im a failure.
CBT therapists who think that helping people to modify their
dysfunctional cognitive processes does have value also hold that the

79
THEORY

persons subsequent responses to their first response are more impor-


tant than their first response in determining whether or not they have
problems. In our example, such therapists would also see the thought/
belief, Im a failure as the persons first response. However, they
would encourage the person to examine this thought for its prag-
matic value and empirical status. Some might even encourage the
person to question the logic in such a thought/belief in response to
failing the driving test. This examination or questioning process and
whatever constructive behaviour flows from it would be regarded by
such modification-based CBT therapists as the persons subsequent
responses to their first response, Im a failure.
Now, the persons subsequent responses to their first response can
be for better or for worse. Lets begin with the situation where they
are for better. In the first scenario in the above example, if the client
puts the acceptance and mindfulness-based CBT therapists sugges-
tion into practice and notices, accepts and acts then these responses
will be tend to be constructive. In the second scenario, if the person
implements the modification-based CBT therapists suggestion and
examines and questions their thought/belief that they are a failure and
acts on whatever more functional thought/belief they come up with
then again these subsequent responses will tend to be constructive.
Now lets see what happens when the persons subsequent
responses to their first response are for worse. First, there are a num-
ber of ways in which the persons responses to the thought/belief
Im a failure can be unconstructive. Here are a few examples:

The person can regard the thought/belief as true with the result
that they decide that there is no point in trying to learn to drive
any more and thus does not sign up for any more lessons.
The person regards that having the thought I am a failure proves
that there is something wrong with them and feels ashamed for
having the thought.
The person can see that the thought/belief I am a failure helps
to explain their depression about failing the driving test and so
endeavours to respond to it so that they completely disbelieve

80
SUBSEQUENT RESPONSES

it. When the thought/belief returns, they consider CBT to have


failed or that they are a failure for still having the thought/belief.
The person regards that the best way to deal with the thought/
belief Im a failure is to distract themself from it with the result
that while they help themself in the very short term, such dis-
traction results in the long-term maintenance of their depression
since its cognitive root still has an impact.
The person tries not to think the thought/belief Im a failure
with the result that they think it more frequently given that
thought suppression tends to result in an increase in thought fre-
quency (Wegner, 1989).

These points are summarized in Table 12.1.

Table 12.1 A range of subsequent responses to the persons first response


to an adversity

Adversity First response Subsequent Impact on


responses well-being
Fails driving Im a failure Accept, notice and act Constructive
test
Fails driving Im a failure Examine thought and Constructive
test act on new thought
Fails driving Im a failure Accept as true Unconstructive
test
Fails driving Im a failure Shame-based Unconstructive
test self-criticism
Fails driving Im a failure Question thought Unconstructive
test until eliminated;
self-criticism when
this fails
Fails driving Im a failure Distraction Unconstructive
test
Fails driving Im a failure Thought suppression Unconstructive
test

81
THEORY

So far I have discussed how a persons subsequent responses to


a problematic cognition can have either a constructive or an uncon-
structive impact on that persons well-being, demonstrating my point
that it is not the persons first response to an adversity that is impor-
tant but their subsequent responses to that first response.

Subsequent responses to the first response:


2.Problematic urges

This concept is particularly appropriate when the issue of dealing


with urges or action tendencies is a central issue for clients. Often
people hold the view that if they experience an urge to do something
that brings them immediate relief or satisfaction/pleasure then that is
the end of the story, they are doomed to act on that urge. For these
people, the solution to their problem is not to experience that urge.
This involves them avoiding situations in which it is likely that they
will experience the urge. When they cant avoid the situation, then
they are likely to do what is shown in Table 12.2.
The therapeutic task here is to help clients see that experiencing
an urge to engage in activity which may bring short-term relief or
satisfaction/pleasure but which is self-defeating in the longer-term is
not in itself the problem. It is how clients respond to the urge. Accep-
tance and mindfulness-based CBT therapists will again encourage
clients to notice the urge, to accept it and then to act in valued ways

Table 12.2 First and subsequent response when unable to avoid situation
in which person experiences urge

Adversity First response Subsequent Impact on


responses well-being
Exposure to situation Urge to engage in Act on the Unconstructive
in which the urge self-defeating urge
is likely to be behaviour
experienced

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SUBSEQUENT RESPONSES

Table 12.3 Two approaches to subsequent responses to the persons first


response to an adversity

Adversity First response Subsequent Impact on


responses well-being
Exposure to Urge to engage in Notice, accept Constructive
situation in self-defeating and act
which the urge behaviour according to
is likely to be values
experienced
Exposure to Urge to engage in Develop healthy Constructive
situation in self-defeating cognitions
which the urge behaviour about urge and
is likely to be act according
experienced to values

even though they may still be experiencing the urge. Modification-


based CBT therapists will help clients to develop healthy cognitive
responses to urges. My own practice here is to help clients under-
stand that while it might be preferable for them not to experience the
urge in question, that does not mean that they must not experience it
and while they might want to act on it, they dont have to do so. Quite
often a combination of these approaches can be helpful. These two
approaches are presented in graphic form in Table 12.3.
SSI-CBT therapists might use such graphics to help clients see
what they are doing with respect to their first responses and how they
could respond more constructively to them.
In the next chapter, I will discuss the importance placed on draw-
ing on a range of client variables during the SSI-CBT process.

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DRAW UPON A RANGE OF CLIENT VARIABLES

13
It is important to draw upon a range
of client variables in SSI-CBT
While the outcome of SSI-CBT does depend, to some degree, on what
you as the therapist bring to the table, as important, or some would
say more important, is what the client brings to the table. While your
skills as a therapist are important, and much of this book is about
what you can do to maximize the chances that the client gets the
most out of the process, the most skilful SSI-CBT therapists will
fail if they dont help their clients to bring the best of themselves to
this therapy. Putting these points together, it is possible to argue that
your most important skill in SSI-CBT is to help the client use the
best of what they have during this process. In this chapter, then I will
discuss what some of the most important client variables are that, if
used, will maximize the chances that the client will get the most out
of the process.

Help the client to identify strengths that they


can draw upon to get the most out of SSI-CBT

While CBT has most frequently been employed to help people identify
and deal with problems or weaknesses, it can be employed to identify
and capitalize on clients strengths. Indeed, Padesky and Mooney
(2012) have outlined a four-stage strengths-based CBT model to pro-
mote resilience, although they argue that it can be employed to foster
other qualities as well. But what is strength? Jones-Smith (2014: 13)
says that strength may be defined as that which helps a person to
cope with life or that which makes life more fulfilling for one and
others. While a number of people have provided lists of strengths

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THEORY

which could theoretically be used to identify client strengths that can


be employed in SSI-CBT (e.g. Buckingham and Clifton, 2014), my
own approach is to focus on what the client thinks their strengths
are that might help them get the most out of SSI-CBT. I will illus-
trate this in Chapter 19 when I discuss the pre-session telephone call
which, in my view, is the best place to discover clients strengths.

Discover which people have been most helpful to


theclient and what they did that was helpful

It is often useful for the client to remember times when they were
helped by someone in their lives. If this was in an area similar
to their target problem, then so much the better. It is particularly
useful to discover what the person did that was helpful, as this
may help you, as therapist, tailor your interventions based on this
knowledge. In addition, it is useful to find out how the client used
the help provided by the other person. Care should be taken to help
the client to understand that it is what they did in response to the
help provided by the other person that made the difference rather
than the help itself. In addition, you should make a note of what the
client did to help themselves and resolve to capitalize on this later
in the process.

Have the client focus on a memorable occasion


of being helped. Encourage them to identify
what was helpful to them

Following on from the above, it can sometimes be useful to ask the


client to recall one memorable occasion of being helped, particularly
if it is different from the above. Again, the focus should be on what
the person did that was helpful so that you may emulate this later and
what the client did themself to make the change so that use can be
made of this information at a suitable time.

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DRAW UPON A RANGE OF CLIENT VARIABLES

Discover which principles the client has found


helpful in life

One of the things that I remember my mother saying to me at various


points in my life is the following: Son, if you dont ask, you dont
get. I took this to mean that if I dont take the initiative in life, then
life wont give me what I am looking for. I need to go for it. Later
on I amended my mothers principle as follows: If you dont ask,
you dont get, but asking does not guarantee getting. I added the lat-
ter phrase to remind myself that there is no universal law that decrees
that I must get what I want or that it must be given to me just because
I am going for it. This revised principle has helped me in two ways.
First, it has helped me to go for things that I wanted, but didnt think
I could get and second, it has helped me to deal with situations when
I went for something, but did not get it.
So a good principle for the purposes of SSI-CBT has the follow-
ing characteristics: (1) it can be expressed in a pithy, memorable way;
(2) it guides action and (3) it promotes coping, preferably in the face
of adversity. As you can see, my revised principle, If you dont ask,
you dont get, but asking does not guarantee getting does all three.
If clients struggle to grasp what I mean by principle then I happily
share with them both the example I have just presented and the char-
acteristics that a good principle for the purposes of SSI-CBT should
ideally have.
When a client identifies with at least one such principle, it is good
practice to make a note of it and be on the alert for opportunities to
use it later to help the client help themself.

Discover the clients role-models

It is useful to discover who the client considers good role-models.


These should preferably be people who, if brought to mind, might
inspire the person to deal effectively with their target problem and
work towards their goal. While a good role-model does not have to

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THEORY

be someone that the person knows personally, it is best if that person


can inspire the client despite being obviously fallible. The response
that you do not want to evoke is: I really admire X, but I cant ever
imagine being able to do what they have done. It is better for the
client to have the idea: Well, they did it and so can I.
Quite often the most successful role-models are people that the
client is very familiar with, looks up to and knows that the person is
on their side someone like a parent, grandparent, another relative,
a good friend or a teacher. However, it is best not to rule anyone
out if they can inspire the client to deal effectively with their target
problem.

Discover how the client best learns

It is important for you to learn something about how your client learns
best with special reference to the target problem at hand. While there
are a number of formal ways to assess a persons learning style, the
reliability and validity of these measures are questionable (Pashler
et al., 2008). However, Pashler et al. (2008) did find that, if asked,
people will tell how they like information presented to them and
I have found that when asked in SSI-CBT, clients can articulate
how they like to learn best when it comes to addressing personal
problems. So, I recommend that you do this and use the information
provided to tailor your interventions accordingly so that your clients
can get the most out of the process.
In the following chapter, I will discuss the client characteristics
that are helpful in the SSI-CBT process.

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HELPFUL CLIENT CHARACTERISTICS

14
Helpful client characteristics for SSI-CBT

In Chapter 7, I discussed who could benefit from SSI-CBT. I focused


in that chapter on what client issues and problems are most amenable
to SSI-CBT. In considering that question, I only outlined one help-
ful client characteristic that might facilitate the process and outcome
of SSI-CBT. In this chapter, I will consider the question of what
are helpful client characteristics for SSI-CBT more comprehensively
and outline ten such characteristics. There are other such characteris-
tics, but these ten are, in my opinion, the most important. I list them
for two reasons. First, you can use them in a checklist to determine
which clients are likely to benefit most from SSI-CBT and second,
they can serve as an aide-memoire for you when you encourage your
clients to demonstrate these characteristics during SSI-CBT and thus
get the most out of the process.

Ready to take care of business now

This was the only client characteristic that I listed in Chapter 7,


regarding who can benefit from SSI-CBT. This is perhaps the most
important client characteristic in that it shows that the client is pre-
pared to work quickly and do what is necessary to solve the problem
in the shortest possible time. Human beings have the capacity to
achieve much in a very short period of time if they demonstrate
this readiness. Recall the case of Vera, discussed in Chapter 5. After
many months of half-hearted engagement in therapy designed to
help her address her elevator phobia, Vera had to deal with this prob-
lem in a very short time in order to save her job. An environmental
change led her to become ready to take care of business now with

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THEORY

excellent results. The questions for you in SSI-CBT are (a) Is my


client ready to take care of business now? And if not, (b) How can I
promote such readiness?

Prepared to be as actively engaged as possible


in the process

I mentioned in Chapter 2 that it is important in SSI-CBT for you


to take an active role in the process, but also at the same time to
encourage the client to be as actively engaged as possible. If your
client takes a passive, feed me stance in SSI-CBT, it is unlikely that
they will get much enduring benefit from the process. So you need
to take every opportunity to promote active client engagement. The
use of focused open-ended questions is one example of how you can
do this.

Open to your ideas as therapist, but able to


disagree with you

The success of SSI-CBT depends on a good blend between what


you bring to the process as therapist and what the client brings
to the process. For your client to get the most out of what you
have to offer, they need to be open to your ideas about factors
that determine their target problem and what they can do to pro-
mote change. But however important that client open-mindedness
is, it is equally important for your client to be able to disagree
with you. Otherwise your client will comply with you but will not
internalize any change principles. Compliance will only last as
long as the therapist is present, whereas internalization will work
in the longer term because the client has made the principle their
own. So, it is important for you to foster an atmosphere where the
client feels free to speak their mind and, in particular, to disagree
with you.

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HELPFUL CLIENT CHARACTERISTICS

Can focus and clearly and specifically articulate


theirtarget problem and related goal

SSI-CBT is a very focused approach to helping clients achieve their


goals in the shortest time possible. In order for this to be done, your
clients need to be able to focus quickly on their target problems and
what they want to get out of their work with you. While such focus
is a key ingredient, it is important that the client is also able to
articulate clearly and specifically the nature of their target problem,
the factors that help determine the problem and what their goals are
in relation to the problem. Both clarity and specificity are important
here. Given that it is important for your client to demonstrate focus,
clarity and specificity, you as their therapist should (a) be mind-
ful of these characteristics when assessing the suitability of clients
for SSI-CBT (clients who have great difficulty focusing in therapy
sessions and expressing their problems and goals with clarity and
specificity are poor candidates for SSI-CBT and (b) encourage these
client characteristics to come to the fore throughout the SSI-CBT
process.

Realistic about what can be achieved in SSI-CBT

I mentioned in Chapter 5 that there is a concept known as quantum


change that was introduced to the literature by Miller and Cde Baca
(2001). They define quantum change which does seem to be rapid
as a vivid, surprising, benevolent and enduring personal transfor-
mation (Miller and Cde Baca, 2001: 4). While it is very unlikely
that such transformation will occur in planned SSI-CBI, it is not
inconceivable that this might happen. More likely, however, is that
the client makes a change that will help them to get unstuck from
a pattern of thinking, feeling and behaviour that has resulted in the
perpetuation of a personal problem from which they have not been
able to free itself. In my view, clients who have realistic ideas of
what they can achieve from SSI-CBT will achieve more than those

91
THEORY

expecting a quantum change. Indeed, I would hypothesize that if


quantum change does occur in SSI-CBT it will be achieved by cli-
ents who have realistic expectations of the process rather than those
actively seeking quantum change.
The two well-known fictional characters that Miller and Cde Baca
(2004) cite as examples of quantum change George Bailey from
the Frank Capra film, Its a Wonderful Life and Ebenezer Scrooge
from the Charles Dickens tale, A Christmas Carol certainly did not
seek quantum change. Indeed, they did not seek change at all. It may
be said, with due poetic licence, that quantum change sought them!
However, they did make use of the opportunity. My view, then, is
that your primary role as an SSI-CBT therapist is to help your client
get the most out of the opportunity that this therapeutic approach
provides rather than trying actively to promote quantum change. If
such change does occur in SSI-CBT, it will happen for reasons only
tangentially related to what you, as therapist, did.

Prepared to put into practice what they learn


fromcontact with you

One of the most robust findings from the literature on CBT is that
clients who put into practice what they learn in sessions get more
out of the process than people who dont put their learnings into
practice. Thus, you would be wise to ask people at the very first
contact (see Chapter 18) or during the pre-session telephone con-
versation (see Chapter 19) whether or not they are prepared to put
what they learn from their SSI-CBT sessions into practice in their
everyday lives. Those who say that they are not so prepared and
cant be helped to change their mind on this issue are, generally,
not good candidates for SSI-CBT and need longer-term therapy to
explore their resistance to this idea.
It is important for you to capitalize on your clients prepared-
ness to practise what they learn by negotiating so-called homework
assignments although you may choose to use different language
here. Such assignments should be closely linked to what has been dis-

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HELPFUL CLIENT CHARACTERISTICS

cussed in the major face-to-face session and be focused on bringing


about change in the clients target problem. It should be appreciated
that in SSI-CBT, unlike in ongoing CBT, there is no opportunity to
review the homework until the follow-up session two to three months
hence.

Can move with relative ease from the specific to


thegeneral and back again

While the ability to focus and specify problems and goals is an


important client characteristic in SSI-CBT, it is also important for
a person to move with facility from the specific to the general and
back again. Too specific a focus will result in the person making
only a very localized change in their life and too general a focus
will result in the client taking away some general principles which
they will find it difficult to apply to concrete situations. In my view,
the ideal situation in SSI-CBT is for the client to be able to address
effectively their target problem, but also understand how general
principles that are relevant to that problem can also be applied to
other problems and/or other relevant situations. As a SSI-CBT thera-
pist, I am mainly focused on the clients target problem, but also
looking for opportunities to help the client to generalize learning to
other contexts in that clients life.

Can relate to metaphors, aphorisms, stories


and imagery

Most therapy involves the use of words. In SSI-CBT, because time


is at a premium, both you and your client are working quite quickly
to make the most of the time available to you collectively. Conse-
quently, you will be exchanging quite a lot of words in your contacts
with one another. One of your therapeutic tasks is to help your client
to create new meaning, which is an instrumental part of the change
process in SSI-CBT. While this new meaning will be in the form of

93
THEORY

words, it needs to be memorable if the client is going to implement it


in their own life over time. One way of making meaning memorable
is to use metaphors (i.e. figures of speech in which a term or phrase
is applied to something to which it is not literally applicable in order
to suggest a resemblance), aphorisms (pithy and memorable state-
ments which contain a general truth and/or an astute observation),
stories and imagery. Clients who relate to such media of expression
tend to have a more emotional impactful experience of SSI-CBT
than those who dont relate as well and may get more out of the
process although this needs to be tested empirically (see Chapter 26).

Prepared to engage in activities where they


can practise solutions in the session

I mentioned emotional impact in the previous section and another


way of increasing such impact with clients is to engage them in
activities where they can practise solutions in the session (see Chap-
ter 27). Role-play and chairwork (see Kellogg, 2015) are good
examples of such activities.

I used roleplay with Susan towards the end of our face-to-face


session in which she realized that the best way of dealing with
her feelings of depression was to assert herself with her boss
who was making unreasonable demands on her at work. I first
helped Susan to see that she was playing the role of helpless
victim at work which helped both maintain her depression and
did not dissuade her boss from giving her extra work every
week. She first decided to stop being a victim and to help
herself by addressing the issue with her boss. In the roleplay,
I played her boss and gave her extra work and she asserted
herself with me. After a few false starts she got into the role
and stood up to me-as-boss very well. She also developed her
own aphorism, Victim no more and resolved to assert herself
with her boyfriend and her mother as well as with her boss.
At follow-up she reported better relations with her mother, a

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HELPFUL CLIENT CHARACTERISTICS

workload on a par with her colleagues and a new boyfriend


who respected her more than the old one who did not like the
new, more assertive, Susan and ended their relationship.

Has a sense of humour

The final helpful client characteristic reflects my personal view and


my personal preference to inject humour into the SSI-CBT process.
For me, the effective use of humour in SSI-CBT enables both you
and your client to treat serious issues with a light touch but without
trivializing the issues. In doing so, it takes the horror out of the issue
and promotes an attitude in the client that, in the words of Albert
Ellis, they can learn to take life seriously but not too seriously. Con-
sequently, I think that clients who do have a sense of humour bring
the best out of me as an SSI-CBT therapist and this encourages me
to help them get the best out of the process.
Having considered what are helpful client characteristics for SSI-
CBT, let me conclude this part of the book by discussing helpful
therapist characteristics for SSI-CBT.

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HELPFUL THERAPIST CHARACTERISTICS

15
Helpful therapist characteristics for SSI-CBT

Not all therapists are suitable or want to do SSI-CBT. Whenever,


I do a workshop on SSI-CBT, the most common objection to the
approach come from people in private practice who are concerned
about their finances. They argue that doing SSI-CBT would not give
them a regular income. While this may be true, it can be dealt with
by charging a higher fee. While sessions may be more expensive,
it is actually the cheapest option when looked at from a treatment
package perspective. So being flexible about charging fees is one
helpful characteristic of therapists who see the value of SSI-CBT.
Let me now consider a range of other helpful therapist characteristics
for SSI-CBT.

Can tolerate lack of information about clients

Another objection to SSI-CBT comes from CBT therapists who


hold that they cannot do therapy without having first carried out a
thorough case formulation. Given this position they argue that the
single-session format just does not give them enough time to carry
out such a case formulation. While there is truth to this position,
SSI-CBT therapists argue that you can practise SSI-CBT effectively
without first having done a case formulation and that, as I argued in
Chapter 10, it is possible to do some formulation work in the time
available, which, when devoted to a thorough problem and goal
assessment, is usually sufficient. Thus, it is useful to be able to toler-
ate not having as much client information as one would like in order
to be a good SSI-CBT therapist.

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THEORY

Does not need close relationships with clients

Another objection to SSI-CBT comes from therapists who argue


that it is necessary to form close relationships with clients to prac-
tise therapy effectively and that the SSI-CBT format does not
give them sufficient time to do this. SSI-CBT therapists would
respond that effective work can be done in SSI-CBT without the
development of close therapistclient relationships and that what
is more important is the development of a good working alliance
(see Chapter 2).

Can quickly engage with clients

In SSI-CBT, what is more important than developing a close rela-


tionship with clients is to be able to engage with them quickly.
This is usually done by focusing very early on their target problem
and what they want to get out of SSI-CBT. However, by eliciting
clients strengths and other variables that will aid you in helping
these clients more effectively, you will engage with clients more
efficiently because they will be focusing on their attributes rather
than just their deficits. In addition, fast engagement is facilitated
by you showing your clients, by your demeanour and your behav-
iour, that you are genuinely interested in helping them as quickly
as possible.

Can be an authentic chameleon

My friend and colleague, the late Arnold Lazarus (1993), introduced


the concept of the therapist as authentic chameleon into the psy-
chotherapy literature, a concept that describes a helpful therapist
characteristic for SSI-CBT. This concept describes you when you
show that you can authentically vary your interpersonal style with
different clients and can astutely determine which clients would

98
HELPFUL THERAPIST CHARACTERISTICS

resonate with which style. SSI-CBT can be practised by therapists


whose style is the same across clients, but my view is that these
therapists will be less effective than therapists who are flexible in
their interpersonal relating with their clients.

Is flexible and has a pluralistic outlook

As I have mentioned several times already, SSI-CBT is best regarded


as a framework rather than a specific approach and can therefore
accommodate different CBT approaches Therefore, CBT therapists
who practise SSI-CBT will bring their own way of using CBT to
the work and I have exemplified my own work [that I refer to as
SSI-CBT (WD)] throughout this book. However, while effective
SSI-CBT therapists will have their own approach they will be pre-
pared to be flexible and pluralistic in the practice of CBT. For you to
demonstrate flexibility and pluralism in SSI-CBT you will do so in
the following ways:

By conceptualizing your clients problems and goals in different


ways if your original conceptualization does not make sense to
the client. When this occurs at the outset, it may indicate that the
client is not suitable for SSI-CBT, but when it happens while the
process is under way, it is then that you can demonstrate your
pluralistic colours in this respect.
By acknowledging that there is no one right way of practising
SSI-CBT. You will, therefore, vary your practice with different
clients and be prepared to use methods both from other CBT
approaches and from approaches from outside CBT when the
situation calls for it.
By bringing a both/and perspective to the work rather than an
either/or perspective.
By drawing on clients resources, which has been discussed in
Chapter 13.
By involving clients fully at every stage of the process.

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THEORY

Can think quickly on their feet

Some therapists prefer to take their time in therapy and to reflect in


a leisurely manner about the process as it unfolds. Such therapists
would find the practice of SSI-CBT quite challenging because it
does require therapists to think quickly on their feet. Therapists who
have this cognitive facility and enjoy opportunities to use it are those
that tend to make effective SSI-CBT practitioners.

Can help the client focus quickly

In an important respect the effective practice of SSI-CBT depends on


you helping your client to find a meaningful focus for the work. If
such a focus cannot be found, then the potency of SSI-CBT as a way
of working is significantly diluted. Thus, therapists who can help
clients focus and can do so quickly, but without rushing them, tend
to do very well in SSI-CBT. This notion of finding a focus quickly
but without rushing the client is crucial. Some therapists can find
a focus quickly but dont bring the client along with them at the
clients speed. Rather, the work has the quality of the client being
dragged along more quickly than they can cope with. The result will
often be that the client will not be able to process properly what is on
offer and will not, therefore, get very much out of the process.

Has realistic expectations of SSI-CBT

I mentioned in Chapter 5, that quantum change, while possible, is


unlikely to be experienced by SSI-CBT clients. Much more com-
monly, SSI-CBT helps clients to free themselves from focused
stuck patterns and get on with their life in a given area. While cli-
ents who have realistic expectations from SSI-CBT will tend to get
more out of the process than clients who think that this approach
will help them change more general chronic problems, the same
is true of therapists. For you to be an effective SSI-CBT therapist,

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HELPFUL THERAPIST CHARACTERISTICS

you will tend to be optimistic, but realistic in what you think you
can help your clients achieve. By contrast, those therapists who, on
the one hand, are pessimistic about what can be achieved or, on the
other, are unrealistic about what clients can get out of the process
tend not to be effective and are perhaps not suited to be SSI-CBT
practitioners.

Can move with relative ease from the


specific to thegeneral and back again

In the previous chapter, I mentioned that an important client charac-


teristic for SSI-CBT was the ability to move quite readily from the
specific to and from the general. This is also a key therapist char-
acteristic, otherwise if an overly specific focus is taken the effect
will be very limited for the client or if a general focus is adopted
then the client will take away only theoretical learning which they
probably wont be able to use in specific situations. However, if an
appropriately specific focus is taken and the client is helped to see
how they can generalize their learning then the SSI-CBT would have
done their job effectively.

Can use metaphors, aphorisms, stories and imagery


andtailor them to the client

Ideally, the process of SSI-CBT should have an emotional impact


on clients (see Chapter 26). This may happen in the normal course
of therapeutic conversation, but it may be enhanced if you employ
a suitable metaphor, a pithy and relevant aphorism, an appropriate
story or an image developed either by the client themself or sug-
gested by you. These methods help encapsulate the main learning
point for the client in a highly memorable way and tend to be remem-
bered both for the methods and the learning point well after SSI-CBT
has finished. Therapists who can readily employ such methods may
be more suited to the practice of SSI-CBT than are therapists who

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THEORY

rely only on straightforward verbal dialogue with the use of such


methods.
This concludes Part 1 of the book which presented the theoretical
underpinnings of SSI-CBT. In Part 2, I will focus much more point-
edly on its practice and, in particular, (a) discuss how to manage the
four points of contact in SSI-CBT and (b) demonstrate how the pro-
cess unfolds by following one clients progress from start to finish.

102
Part 2

PRACTICE
GOOD PRACTICE

16
Good practice in SSI-CBT

Before I discuss, in detail, the four points of contact in SSI-CBT, let me


outline what I consider to be good practice in SSI-CBT. These are gen-
eral points of practice which, if implemented, will facilitate the process
and outcome of SSI-CBT. In what follows, I will briefly review 23 gen-
eral ways of intervening that characterize good practice in SSI-CBT.

Engage the client quickly

SSI-CBT is an approach to helping people that involves you using time


very efficiently. There is no time to waste on conversation that is not
focused on the task at hand. Thus, engaging the client quickly is very
important to enable the process to get off on the right footing at the outset.

Develop rapport through the work

In SSI-CBT there is no distinction made between rapport building


and getting the work done. Indeed, it is argued that the best way of
developing rapport with clients to is show them that you are very keen
to help them address their problems and goals as quickly as possible.

Be clear about why you are both here and what


you both can and cant do

If the client is going to get the most out of SSI-CBT it is impor-


tant that you and they both share the same ideas about what

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PRACTICE

the purpose of your contacts are and what can be realistically


achieved from these contacts. It is your responsibility as thera-
pist to ensure that both of you share the same views on these
matters.

Be active-directive

In general, CBT is a therapeutic tradition where you are called


upon to adopt an active-directive therapeutic style. It is no differ-
ent in SSI-CBT where, from the outset, you need to be active in
directing yourself and your client to the latters target problem and
what they want to get out of such discussion. However, you need to
ensure that in adopting an active-directive style, you also encour-
age your client to be active in the process. If the client is rendered
passive by your activity then they will probably derive little benefit
from SSI-CBT.

Be focused and help the client stay focused

With respect to the issue of focus, you have two important tasks to
perform. First, you have to help the client to identify a focus for
the work e.g. a problem that they are stuck with for which they
would like help to get unstuck and second, you need to help the
client stay focused on this target issue. Clients vary in their ability
to stay with a focus once it has been jointly created and it is your
job to help them do this, by your questions and, if necessary, by
interrupting the client and re-directing them back to the focus. As I
have already mentioned, but it is a point worth repeating, it is best
if (a) you explain in advance that you may need to interrupt the
client if they move away from the agreed focus and (b) you ask for
permission to do so.
It should also be clear that the therapist needs to guard against
moving away from the agreed focus themself.

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GOOD PRACTICE

Assess the problem with an imminent,


future example if possible

Once you have elicited the problem from the clients perspective,
the next stage is assessment. In general, at the outset, CBT therapists
will usually assess examples of problems, either examples that are
occurring in the clients present or have occurred in their recent past.
In SSI-CBT, this may also be done, but I suggest that, if possible,
you assess an imminent, future example of their problem. The ratio-
nale for this is as follows.
The goal of SSI-CBT is to help the person quickly set a goal and
take away a new perspective that will allow them to move on with
their lives. Thus, both you and your client are facing forwards, as it
were. When you assess a past or current example of the clients prob-
lem then you are both facing backwards or sideways. When it comes
to negotiating a homework assignment the sideways and backwards
facing therapeutic dyad have to adjust their position and face for-
wards whereas the forward facing pair are already facing in that
direction. This shows that starting with assessing the target problem
with an imminent, future example, if possible, is the more efficient
strategy since putting new learning into practice will be done in the
setting that has already been assessed.
In explaining this rationale to clients, I may say something like:

In my view, the limited time that we have with one another


is best spent on seeing how you can best implement what you
may learn here to your life going forward. Given this, I think
that the more we can focus on imminent, future examples of
your problem the more likely it is that you will apply what you
learn here to those situations when you face them. What is your
response to this strategy?

If the client disagrees with this strategy, then we can use that dis-
agreement as a springboard to agreeing on a way forward to which
we can both sign up. Here, as elsewhere, preserving the alliance is

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PRACTICE

more important than pushing the client into working with a strategy
to which they are opposed, no matter how much this strategy might
represent good practice in SSI-CBT.

Elicit the clients goal and keep focused on this

CBT therapists, in general, are goal-oriented and this is even more


the case in SSI-CBT. Once a workable goal has been identified then
it is good practice for you to help the client keep your joint focus on
this goal whether this be a goal in the face of adversity (see Chap-
ter 4) or not. I will discuss working with goals in SSI-CBT in greater
detail in Chapter 23.

Ensure that this goal-oriented focus is underpinned


by a value if possible

As an SSI-CBT therapist, you will be aware of the limited time that


you have with your clients and therefore you need to discover ways
of increasing the chances that what clients achieve from the pro-
cess endures. One way of doing this is to help the client to find an
important value that might underpin their goal, since goals that are
underpinned by values are more likely to be achieved than goals that
arent (Eccles and Wigfield, 2002). I will discuss this issue further
in Chapter 23.

Ask what the client is prepared to sacrifice


toachievetheir goal

SSI-CBT is based on a blend of optimism and realism. It is opti-


mistic in the sense that it holds that clients can be helped to address
effectively their target problems in a single face-to-face session
when proper preparations have been made for that session. It is real-
istic in the sense that it acknowledges that clients are more likely to

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GOOD PRACTICE

achieve their goals if they are prepared to make sacrifices to achieve


their goal. Therefore, it is good practice for you to raise this issue
with your clients at the appropriate time.

Whenever practicable, explain what you plan to do


inSSI-CBT and seek the clients permission toproceed

In my view, it is good practice in SSI-CBT to explain, whenever


practicable, what you plan to do so that the client understands it and
is fully on board with it. There is no time for you to explain every-
thing you plan to do and neither would it be wise for you to do so,
as this would interfere with what you are both there for helping
the client move on with their lives as quickly as possible. However,
whenever you are likely to adopt a strategy that the client might not
realistically expect or may struggle to understand, then it is wise to
offer a rationale and ask for permission to proceed. Here are a few
additional examples of strategies where you might usefully explain
what you plan to do and seek permission to proceed:

discussing a specific example of the clients target problem;


questioning the clients problematic cognitions;
interrupting the client if they go off track;
offering a relevant piece of therapist self-disclosure.

Encourage the client to be specific as possible but be


mindful of opportunities for generalization

I have mentioned several times already the importance of specificity


in SSI-CBT. Working with such specificity has several advantages:
(1) it helps both you and your client understand more clearly the
factors that explain why the problem persists; (2) it is more likely
to engage the client emotionally with the process than will keeping
things general; and (3) it gives both you and your client a clear vision
of what the latter might change to achieve their goals.

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PRACTICE

However, it is also important for you to be mindful of opportu-


nities to help clients generalize their learning. Thus, managing the
specific-general continuum and moving flexibly along this contin-
uum in both directions represents good practice in SSI-CBT. Doing
so will help the client get as much out of the process as possible.

Identify and make use of the clients strengths

As I discussed in Chapter 13, it is important that you seek infor-


mation about a number of client variables to assist them to get the
most out of the process. One of these variables client strengths is
particularly useful. Thus, it is good practice to base SSI-CBT on the
strengths which clients can bring to the process than just focusing on
their problems.

Identify previous attempts to solve the problem;


capitalize on successful attempts; distance yourself
fromunsuccessful attempts

The efficient use of time is paramount in SSI-CBT, Therefore,


it is important that you do not waste time by trying to help cli-
ents in ways that they have already tried and at which they have
failed. Thus, it is good practice in SSI-CBT for you to discover
what your client has already done to address their problem and
to capitalize on things they have tried that yielded some success
and to distance yourself from things they have tried that proved
unsuccessful.

Identify and be mindful of the clients learning style

As I mentioned in Chapter 13, it is important for you to plan your


interventions with your clients learning style in mind. Asking your
client how they best learn with respect to their problem is direct and

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GOOD PRACTICE

may yield the explicit information you need to help them get the best
from SSI-CBT.

Encourage the client to prepare and reflect


throughoutthe process

In order to encourage your client to get the most out of the SSI-CBT
process, it is good practice for you to encourage them to prepare
themselves for different parts of the process and to reflect on these
different parts.

Encourage the client to prepare


In my practice of SSI-CBT, I encourage my clients to switch off
their mobile phones and tablets 30 minutes before the pre-session
telephone contact, the face-to-face session and the follow-up ses-
sion so they can properly prepare for each point of contact. For the
pre-session telephone session, I want them to think about (a) the
resources that they can bring to the process to achieve whatever their
goal is and (b) what I, as therapist, can bring to the process to help
them to do this. For the face-to-face session, I want them to think
more precisely about what their specific goal is and how they think
they can achieve it and again how I can be most useful in helping them
achieve it. For the follow-up I want them to think about what they
achieved from the process and what they did to bring about what
they achieved. I also want them to think about what was helpful and
unhelpful about the process and what I could have done differently
to help them effectively.

Encourage the client to reflect


It is also my practice to encourage my clients to refrain from turn-
ing on their mobile phones and tablets for 30 minutes after the
pre-session telephone contact and the face-to-face session so that
they can reflect on what they have learned from these two points of

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PRACTICE

contact. After the pre-session telephone contact, I encourage them to


think about what they learned from this contact and how they can use
it to get the most out of the face-to-face session. After the face-to-
face session, I again encourage them to reflect on what they learned
from this contact and how they can apply this learning in their lives
with respect to the target problem and also other related areas.
To aid reflection, I also send them after the face-to-face session a
copy of the digital voice recording (DVR) that I routinely make of my
single sessions and also the transcript of this recording. I encourage
them to refer to one, or other or both of these materials when they wish
to refresh their memory of the work we have done together. I discuss
the use of these recordings more fully in Chapter 29 and Appendix 1.

Make liberal use of questions

If you have been trained in CBT, you will be comfortable with the idea
of asking questions. However, if you were originally trained in the
humanistic and psychodynamic approaches you may have problems
with this aspect of SSI-CBT practice since these approaches tend to
caution against the liberal use of questions. As asking a lot of questions
is the sine qua non of SSI-CBT practice, you will need to adjust to this
core component of the approach if you are to practise it effectively.

Ensure that the client answers the


questions you askthem

In my view, questions in SSI-CBT are like surgical incisions in that


they are designed to get to the heart of the matter. Given the impor-
tant role that asking questions has in SSI-CBT, it is good practice for
you to ensure that the client does, in fact, answer the questions you
have asked them. If they have not answered an important question
then you need to ask it again until the client does answer it. This
should be a focused, but gentle process and not an interrogation.
However, if the client continues to struggle to answer the question,

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GOOD PRACTICE

then you should drop the question and take a different tack, even if
the question is really important as to persist will threaten the working
alliance, which should be avoided if at all possible.

Give the client time to answer your questions

One of the things that experienced SSI-CBT therapists are able to do


is to use time effectively without seeming to rush the client. Mesut
zil, who plays for Arsenal is a football player who is able to get the
job done while seeming to take his time doing so. In training SSI-
CBT therapists, I show video clips of zil playing to demonstrate
what I mean. Doing an zil has come to mean making sure that the
client answers the therapists questions, but giving them time to do
so. Thus, making effective use of the time at your disposal without
rushing your client is a hallmark of good SSI-CBT practice.

Check out the clients understanding


of your substantivepoints

What is the difference between teaching and learning? Teaching is the


input provided by the teacher, while learning is what the learner takes
away from the process. I mention this point because it is relevant to
SSI-CBT. Thus, if you make a substantive point during the process
then it is important that you ask the client for their understanding of
the point made. Otherwise, you may think that the client may under-
stand when they dont. There is no good course without a test!

Identify and respond to the clients doubts,


reservationsand objections including those that
may be expressed non-verbally

I have mentioned several times already that it is important that you


and your client are in agreement about different facets of the SSI-
CBT process. If not, then the client wont derive as much benefit

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PRACTICE

from SSI-CBT as they could if you both agreed on these facets.


Given this, it is good practice for you to ask the client if they have
any doubts, reservations or objections (DROs) about any aspect of
the process. Otherwise the DRO(s) will still exist and exert a nega-
tive impact on the process with unconstructive results for the client.
Sometimes the client will indicate nonverbally that they have a
DRO about the process. When you notice this, you should check it
out with the client and deal with the issue that the client expresses.

Look for ways of making an emotional impact

In CBT the distinction is made between intellectual insight and


emotional insight (Ellis, 1963). By intellectual insight is meant
a theoretical understanding of a salient point, while by emotional
insight is meant a deep conviction in the same point that impacts on
the persons feelings and behaviour. In ongoing CBT, the path from
intellectual insight to emotional insight is usually made by the exe-
cution of relevant homework assignments which are negotiated and
reviewed and carried out over time. In SSI-CBT, there is insufficient
time to promote this process in this way. Consequently, you need to
look for ways to make an emotional impact with the client some time
in the face-to-face session, if possible. While benefit can be derived
from SSI-CBT without such impact, such benefit is enhanced with
it, in my experience.

Try to ensure that the client takes one meaningful


point from the process and has a plan to implement
thispoint

I have raised the issue several times in this book concerning what
can be realistically expected from SSI-CBT. My view on this point
is that if you can help the client take one meaningful point from
the process with a plan to put this point into practice then I think
that you have done their job. Sometimes, however, when I think that

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GOOD PRACTICE

the client has done this then it transpires that nothing fruitful has
occurred for the client and the converse is true; that when I think that
the client has not taken anything meaningful from the process then
they have derived great benefit. Having said this, it is good practice
for therapists to strive to help the client take a way a plan to imple-
ment that one meaningful point (Keller and Papasan, 2012).

Summarize or have the client summarize the session

Because the goal of SSI-CBT is to help the person take something


meaningful from the process, it is useful for you to ensure that the
client is clear about what is happening throughout the process. There-
fore, periodically, it is good practice to summarize what has been
covered or have the client summarize. The most important summary
is at the end of the face-to-face session as this is the point that will
influence what the person puts into practice.
Because the end of the face-to-session is important it is important
that the client does not go away from it wishing that they had asked
something or go away confused on some issue. Consequently, it is
important that you tie up any loose ends with the client before they
leave the face-to-face session.

Plan for and carry out follow-up

The follow-up phase of SSI-CBT is an important part of the process


and thus you need to provide a rationale for it and organize when the
follow-up session will take place before the client leaves at the end
of the face-to-face session. So I suggest that you make a definite time
for the contact, which is generally conducted over the phone roughly
two or three months after the face-to-face session. It needs to be at a
time when the client can talk freely without interruption.
Having outlined what is good practice in SSI-CBT in the fol-
lowing chapter I will provide an overview of the process before
discussing each part of that process in detail in the rest of the book.

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AN OVERVIEW OF THE SSI-CBT PROCESS

17
An overview of the SSI-CBT process

Before I discuss in detail the process of SSI-CBT, I will first present


an overview of this process. Let me be clear at the outset that this
process comes from my own practice of SSI-CBT and it may be that
other therapists may conceptualize this process somewhat differ-
ently. Some may, for example, see it as one point of contact after the
appointment has been made. I think, though, that for it to be prop-
erly classified as single-session therapy that there should only be
one face-to-face contact. Remember, my definition of single-session
therapy which I outlined in Chapter 1. I said there that SST (and by
extrapolation SSI-CBT) involves:
One main face-to-face meeting between a therapist and a client
with no previous or subsequent main sessions within one year, up
to two nonface-to-face brief meetings prior to the main session to
arrange and get the most out of the main session and one follow-up
session.
Thus, the process of SSI-CBT as discussed in this book involves
four points of contact:

a first contact;
a pre-session telephone contact;
a face-to-face session;
a follow-up session, usually by telephone.

The first contact

A first contact represents the first time that the person seeking help
makes contact with you or with the clinic where you work. While I
will discuss this further in the next chapter, let me say here that the

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PRACTICE

main objectives of the first contact are as follows. First, you or who-
ever responds to the person at the first contact outlines the services
on offer. Second, if the person wants to be considered for SSI-CBT,
then the next stage is either to rule out the person as a candidate
for SSI-CBT or to make a judgment that the person is potentially a
good candidate for the process. In the latter case, arrangements are
then made for the person to have a pre-session telephone contact ide-
ally normally and ideally with the person who will be their SSI-CBT
therapist, i.e. you.

The pre-session telephone contact

The pre-session telephone contact lasts usually between 20 and


30 minutes and, as I said above is usually carried out by you as thera-
pist. The first purpose of the contact is for you and the person seeking
help to come to a more definite decision concerning the suitability of
the person for SSI-CBT. The second purpose of the telephone call is
to help both you and your client to prepare yourselves for the face-
to-face session. I will discuss the points to cover in this second point
of contact in Chapter 19.

The face-to-face session

The face-to-face session usually lasts for approximately 50 minutes


(unless there is good reason to extend it). The first thing that you
do is to pick up on the preparatory work that the client did between
the end of the phone contact and this session. In addition, you need
to enquire about any changes that the client may have noticed since
they had the phone call.
Your next task is to help the client to create a focus for the session
and then to identify the persons target problem (i.e. the problem they
want to be helped with) and the goal with respect to that problem.
Problem and goal assessment follows, based on a selected example
of the problem1 and during this assessment, if all goes well, you need

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AN OVERVIEW OF THE SSI-CBT PROCESS

to help the person to develop a working understanding of the model


that underpins the assessment. The next stage is for the person to
examine the troublesome cognitions that are deemed largely respon-
sible for the problem and either to modify these and plan on acting on
the new cognitions or to accept the problematic cognitions mindfully
and thence act in valued ways or a combination of the two strate-
gies. Throughout this process you need to look for ways to help the
client to generalize learning. During this last task it is useful if you
can find a way to make an emotional impact on the client which may
encourage learning and later application.
Then, if relevant, you might encourage the client to practise a
possible solution to their problem in the session (e.g. with role play
or chair work). After which some discussion should take place con-
cerning how the client is going to implement their learning in their
everyday life as soon as possible after the session. At the end of the
session a final summary should be made preferably by the client and
augmented by you and any loose ends tied up. A definite appoint-
ment should be made for the follow-up session two to three months
in the future.
One of the features of my practice [SSI-CBT (WD)] is that I record
the session and offer my client the digital voice recording (DVR) of
the session and/or a typed transcript of the session. I find that doing
so aids client reflection and gives the client something to review after
the final session and provides a useful bridge between the face-to-
face session and the follow-up session. However, it should be noted
that not every SSI-CBT therapist does this.

The follow-up session

Some clients say that knowing that they were going to have further
contact with the therapist was a motivation to help them maintain
the gains that they made from the session. Others welcome the
chance to reflect on the process and it also serves as a reminder of
what was achieved since the face-to face session and what can yet
be achieved.

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PRACTICE

Follow-up also enables you to discover what was helpful and


not so helpful about your contribution to the process and thus, it
aids your development as an SSI-CBT therapist. Finally, if you are
working in a service that collects data on intervention effectiveness,
follow-up is crucial in finding out just how effective SSI-CBT is
with certain groups and populations. It also yields data on differential
effectiveness among therapists.
In the chapters that follow, I discuss good practice at each of these
points of contact in further detail and provide illustrations from my
work with an SSI-CBT client.

Note

1 See Chapter 16 for a brief discussion of the value of working with an


imminent, future example of the target problem.

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THE FIRST CONTACT

18
The first contact

From an SSI-CBT perspective, the purpose of the first contact


between you and the person who has made that contact is for you
both to make an initial judgement concerning the persons suitability
or otherwise for SSI-CBT.
How that contact is made will depend upon your working envi-
ronment. If you work for yourself and take your own phone calls, you
will be able to explain to the person who has called you what services
you offer, in general, which will include single-session work. If you
work in an agency where a receptionist, for example, is the first port
of call for potential clients then the agency should ideally train the
receptionist in being clear about the services that the agency offers,
which will include single-session therapy.
In what follows I will assume that you, yourself, will be the per-
son who will be the first point of contact for your potential client.
Whether you have answered the telephone when the person rings
or whether you are returning their call, I recommend that you first
ascertain whether or not the person has contacted you specifically
for single-session therapy or whether they are requesting some other
service. If they have contacted you for single-session therapy specifi-
cally then I suggest that you ask them what it is about the approach
that has attracted them and continue from there. If they have con-
tacted you for some other service, for example, ongoing CBT, then
you have a choice. Either, you can offer them an appointment for
ongoing work or you can outline the services that you offer to ensure
that they know the full range of services and are making an informed
decision. Outlining the range of services that you offer is a good idea
particularly when the person who has called is not sure, at that time,
which service may meet their therapeutic needs. In my own case,
I outline the four services that I offer in my practice: (1) ongoing
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PRACTICE

therapy; (2) single-session therapy; (3) coaching; and (4) couples


therapy.
In this part of the book, I will be referring to the single-session
work that I did with Eugene,1 a 25-year-old accountant who contacted
me for help with anxiety concerning work-related presentations that
he was called upon to give as part of his employment. What follows
has been taken from the first contact that Eugene and I had.

Eugene: I was given your number by my sister-in-law who


thought that you might be able to help me.
Windy: Do you have any idea what particular type of help you
are looking for?
Eugene: Well, I was told that you practise CBT, but other than
that Im not sure.
Windy: Would it help if I outlined services that I do offer?
Eugene: Yes.
Windy: First, I offer ongoing CBT which is mainly for people
who have either one chronic problem that they have
struggled with for many years or a range of problems
but they are looking to address. Second, I offer single-
session CBT for people who have one problem that they
are stuck with but they are keen to address as quickly
as possible so that they can move on with their lives
without being constrained by that problem. Third, I offer
coaching for people who dont have any specific or gen-
eral problems in their lives, but have a sense that they
are not getting as much out of their life as they could get
either in their personal lives, their work lives, or their
relationship. Finally, I offer couples therapy for people
who have relationship problems which they want to
address together with me as their therapist. Which of
these services do you think at the moment best suits you
and your situation?

During this part of the first contact, you may begin to get a sense
of what the person is like with respect to how specific or vague

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THE FIRST CONTACT

their answers are. If their answers are vague my practice is to try to


encourage them to give more specific answers. If they find this diffi-
cult, then it may be that they are not suitable for SSI-CBT which does
require them to be quite specific at the outset. If I have a strong sense
that they are not suitable then I try to find a diplomatic way of saying
so and to suggest that ongoing CBT might be more suitable for them.
If I have begun to form an impression that the person may be suit-
able for SSI-CBT then I explain a little bit more about the process so
that they can make a more informed decision concerning whether or
not to proceed with SSI-CBT.
After Eugene had indicated that he thought that SSI-CBT was the
most relevant service for him, I proceeded with this.

Windy: So let me explain a little bit more about the single-session


therapy process. In a few days I would like to organize a
short telephone session with you lasting between 20 and
30 minutes where we can talk some more about whether
the single-session approach is the best service for you and
if we agree that it is, we can both plan to get the most out
of the face-to-face session which will take place about a
week after we have spoken on the telephone. The face-to
face session lasts up to 50 minutes. Then, about two or
three months later, we will have another telephone con-
tact where you can feed back to me the progress that you
have made since we spoke. Do you have any questions?

At this point, the major question people have is about cost. I inform
them about the charge for the entire process, but then indicate that the
cost is staggered and a set amount is payable at the end of the tele-
phone contact and the outstanding amount is due at the end of the
face-to-face session. This cost includes a copy of the digital voice
recording and a copy of the transcript of the session. I will discuss
the role of the recording and the transcript in Chapter 29. Other SSI-
CBT therapists ask for the cost of the entire process up front. I also
inform the person about other practicalities, such as my cancellation
policy and the exceptions to absolute confidentiality.

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PRACTICE

After I have answered all the persons questions, I arrange a set


time for the person to telephone me. I ask them to ensure that we
will not be interrupted and that they choose a place where they can
talk openly and give me their full attention. I suggest that they have
a notebook at hand in case they want to make notes. I ask them that
if they want to prepare for the telephone call, they might like to write
down as specifically as they can what problem they want to address
and what they would like to achieve with respect to that problem
given the limited time that we will have with one another.
In the next chapter, I will discuss the pre-session phone call.

Note

1 The case of Eugene is a composite case. This means that the work has
been drawn from a number of different SSI-CBT cases that I have seen.
The exchanges that I report when discussing SSI-CBT with Eugene did
not actually take place but are highly representative of the work that I do
with clients in my SSI-CBT practice.

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THE PRE-SESSION PHONE-CALL

19
The pre-session phone-call

There are a number of ways that you can conduct pre-session phone
calls, but perhaps the best way in my experience is for you to do so
while referring to a checklist of topics that you have already pre-
pared. As you prepare your checklist of topics, it is important that
you are mindful of the purpose of the pre-session phone call. First, if
you have remaining doubts that the person is suitable for SSI-CBT, it
is important that you begin the phone call by addressing such doubts
and these should be represented on your checklist. Once you and
your client have agreed that the latter will go forward with SSI-CBT,
then the items on your checklist should be designed to help you to
assist the client to get the most out of the process as possible. I can
explain this best by comparing a handheld juicer (see Figure 19.1)
with a professional blender (see Figure 19.2).
While the handheld juicer will do an adequate job of extracting
the juice from an orange, for example, the professional blender will
extract far more juice while leaving behind the unwanted pulp. I
liken the checklist that I use in the pre-session phone contact with the
professional blender rather than the hand-held juicer in that the ques-
tions that I ask on my checklist are designed to help me get as much
information to help the client in the face-to-face session as possible.
In Box 19.1, I reproduce the list of questions that I ask in the pre-
session phone-call once the client and I have decided that they are
suitable for SSI-CBT and they have given verbal informed consent
to proceed.1 While the client is talking, I will be making notes in the
space between the questions based on what the client says. I also
suggest that the client makes notes for themself. The protocol is a
flexible framework and I am free to ask questions that are not on the
list based on how the conversation between us unfolds.

125
Figure 19.1 Helping the client get the most out of the SSI-CBT process:
the handheld juicer

Figure 19.2 Helping the client get the most out of the SSI-CBT process: the
professional blender
THE PRE-SESSION PHONE-CALL

Box 19.1 Pre-session telephone protocol


1. What made you decide that now is the right time for
therapy?
2. How do you anticipate the issue could be solved?
3. How soon do you think the issue could be solved?
4. How do you think I can best help you to deal with the
issue?
5. What are the factors (or circumstances) that have contrib-
uted to the issue?
6. What have you tried to do that has helped with the issue?
7. What have you tried that has not helped with the issue?
8. What core values do you have that we might refer to in our
work together in addressing your problem?
9. What strengths do you have as a person that you can use
that might help you address the issue?
10. Can you tell me about an occasion where you made a
significant change in outlook in a very short period of
time?
11. Who do you consider to be a role model who might
directly or indirectly be helpful to you as you deal with
the problem?
12. I would like to know what your preferred way of learning
is so that I can tailor the session to best help you. Can you
help shed light on this?
13. Between now and our face-to face-session, I want you to
notice the things that happen to you that you would like
to keep happening in the future relevant to the problem.
In this way, you will help me to find out more about your
goal.
14. Is there anything that you would like me to know that will
help me prepare for our face-to-face session or that would
help us get the most out of the session?

127
PRACTICE

In Box 19.2, I present my notes2 from the pre-session phone con-


tact between myself and Eugene together with my clinical thinking
about what he said.

Box 19.2 Pre-session telephone protocol: Eugene


1. What made you decide that now is the right time for
therapy?
He has decided to apply for new jobs and there is a good
chance that he will need to give a group presentation. He
wants to address his fear of giving such presentations,
preferably before such presentations
2. How do you anticipate the issue could be solved?
He is hoping that I will give him some tips to help him. I
asked him what kind of tips, but he was rather vague. I
asked him whether he thought there was a link between
his anxiety about speaking in public and his attitude
about certain aspects and he readily agreed.a So, that
is encouraging that he is open to the ABC framework.
I asked him to think in preparation for the face-to-face
session about how this link applied to him by imaging
that he was anxious about giving a group presentation
imminently
[Note that I suggested a future focus here]
3. How soon do you think the issue could be solved?
He was hoping that he would be able to solve the problem
before being called for a job interview and give a
group presentation as part of that process. I mentioned
that the more practice he was willing to get before that
time, the more likely it was that he would achieve his
objective. He agreed, which was encouraging

128
THE PRE-SESSION PHONE-CALL

4. How do you think I can best help you to deal with the
issue?
He replied to this by picking up on my suggested link
between anxiety and attitude and said that he hoped
that I could teach him an attitude that might help him
solve the problem
[When a client spontaneously picks up on the BC
link that you may have outlined this is a particularly
hopeful sign that they may be able to use SSI-CBT]
5. What are the factors (or circumstances) that have con-
tributed to the issue?
Eugene mentioned in this context that he was shy as a
child and adolescent and avoided speaking to new
people. Now he can speak with new people but avoided
giving presentations which he saw was an extension of
his shyness
6. What have you tried to do that has helped with the
issue?
Eugene said that nothing has really helped apart from
taking beta-blockers before group presentations at one
point and alcohol at another point. He only did this
when he could not get out of giving the presentation.
Otherwise he avoided giving the presentation.
At this point I picked up on something Eugene said a little
earlier that he used to be shy as a child and adolescent
and avoided talking to new people, but this was no
longer a problem for him. He said that he just pushed
himself to talk to people and after a while he became
more comfortable with them. I wondered aloud what
would happen if he adopted the same principle with
group presentations. He said that he hadnt thought

129
PRACTICE

about it like that, so I asked him to think about it


before the face-to-face session. He did say that the
difference was that all eyes would be on him when he
gave the presentation and what he dreaded was that
people would see him being shy and awkward. I asked
him to think how he dealt with that issue when talking
to new people more on a one-to-one basis when he was
addressing that problem
[There are two points to note here. First, Eugene had in
the past applied an exposure principle while tolerating
discomfort when he addressed his fear of talking to
new people, so I knew that this could be useful here
too. Note that I asked him to reflect on this point. The
second point to note is that I hypothesized from what
Eugene said that his particular adversity in giving
group presentations was being seen to be shy and
awkward. This was his A in the ABC framework. I
asked him to reflect on how he dealt with this issue
more on a one-to-on basis]
7. What have you tried that has not helped with the issue?
Eugene said that he tried hypnosis but it was not helpful.
He said that the hypnotherapist recommend that he
should imagine himself being very socially polished
while giving a group presentation, but did not help
him deal with coming across as shy and awkward. I
stressed that I would help him deal effectively with this
adversity
8. What core values do you have that we might refer to in
our work together in addressing your problem?
Eugene thought that honesty was the core value that
would be most helpful in our work together

130
THE PRE-SESSION PHONE-CALL

9. What strengths do you have as a person that you can


use that might help you address the issue?
Eugene said that he thought his biggest strength was
determination
10. Can you tell me about an occasion where you made a
significant change in outlook in a very short period of
time.
Eugene could not think of any such occasion
11. Who do you consider to be a role model who might
directly or indirectly be helpful to you as you deal with
the problem?
Eugene mentioned that he had always looked up to his
paternal grandfather who despite adversity managed
to keep cheerful. I asked Eugene what his grandfather
taught him either directly or indirectly. He replied that
his grandfather was fond of saying, What is very bad
now, will not seem so bad in the morning. I asked
Eugene to think of ways of applying this philosophy to
his problem about giving group presentations
12. I would like to know what your preferred way of learn-
ing is so that I can tailor the session to best help you.
Can you help shed light on this?
Eugene said that he learns best by taking his time to
think things through. He mentioned that he already
appreciated that I had encouraged him to think over
several points and wasnt rushing him. He mentioned
that he hated being rushed. I responded by wondering
to what extent he would rush himself if he were to give
a group presentation and what would happen if he
gave himself some time

131
PRACTICE

13. Between now and our face-to face-session, I want you


to notice the things that happen to you that you would
like to keep happening in the future relevant to the
problem. In this way, you will help me to find out more
about your goal.
Eugene agreed to do this
14. Is there anything that you would like me to know that
will help me prepare for our face-to-face session or
that would help us get the most out of the session?
Eugene could not think of anything but said that he would
email if anything occurred to him
a
In REBT this link between attitude and emotion is known as the BC
connection, a very important part of the ABC framework.

Before ending the phone-call, it is useful to ask the client to sum-


marize what we covered in the contact. You can fill in the blanks if
the client has missed out on any salient points. The last thing to do is
to make a specific date for the face-to-face session.

The email summary

I mentioned above that at the end of the phone session it is useful to


ask the client to summarize the salient points of your conversation.
It is also useful, sometimes, to send the client a brief summary of
what you have discussed and a list of anything that the person has
agreed to do before the face-to-face session. In my experience, it is
best to ask the client at the end of the phone if they would like such a
summary as they may not require it. In Box 19.3, I present the email
summary that I sent Eugene at the end of the session.

132
THE PRE-SESSION PHONE-CALL

Box 19.3 Email summary: Eugene


You have decided to seek help because you anticipate having
to give group presentations as part of a job interview process
in which you plan to involve yourself. As we spoke you could
see the link between your anxiety about giving group presen-
tations and your feelings of anxiety and I asked you to think
in preparation for the face-to-face session about how this link
applied to you by imagining that you were anxious about giv-
ing a group presentation imminently. You are keen to solve the
problem quickly, but recognise that such speed will be depen-
dent upon practice. You thought that I could be most helpful
by helping you to develop an attitude that might assist you in
solving the problem.
You used to be shy and did not speak to new people, but
over time, by pushing yourself to talk to them, you became
more comfortable doing so. I suggested that you think about
how you could use this facing-up principle with the group pre-
sentations. You recognized that doing so meant facing up to
being seen as shy and awkward.
You mentioned that you had tried hypnosis, but that it had
little or no effect because it did not help you deal with coming
across as shy and awkward which we will do in the face-to-
face session.
You also mentioned that the major strength that you can
bring to the table here is your determination. The role model
that could best help you with your problem was your grand-
father on your fathers side who taught you the maxim What
is very bad now, will not seem so bad in the morning. I asked
you to think of ways of applying this philosophy to your
problem about giving group presentations. You learn best by
taking your time to think things through and hate being rushed.
I wondered if there was a relationship between your anxiety
about giving group presentations and self-rushing. You agreed

133
PRACTICE

to think about this before our face-to-face session. You also


agreed to notice any changes with the problem before our
face-to-face session.
I look forward to seeing you at the face-to-face session.

When the pre-session contact is sufficient

Sometimes it happens that the client has got what they required
from SSI-CBT from the first contact and the pre-session contact and
chooses to exit the process at this point. When this happens, it tends
to be for one or more of the following reasons.

1. Speaking about the problem enables them to


put the problem into a different perspective
During the pre-session contact you will probably ask the person to
state what problem they seek help for. This might be the first time
they have verbalized it and the act of doing so may enable them to
stand back and see the problem in a different and more constructive
light. When the person can maintain such perspective, they decide
that they have got what they want from the process.

2. Speaking about the problem helps them to


formulate a constructive course of action
Speaking about the problem with you may also help the person
formulate a way of tackling the problem that the person has not con-
sidered before and doing so provides them with the impetus of trying
it out. When they do so, and it yields a positive response, then the
person is given hope that they are on the way to solving the problem.
When this happens then it is important that you stay out of their way
and let them get on with it by themself.

134
THE PRE-SESSION PHONE-CALL

3. Reviewing their strengths helps the person


realize that they have the resources to address
their problem on their own
When people focus on their problems they usually concentrate on
their deficits. Asking your client what strengths they might bring to
SSI-CBT may encourage them to get in touch with resources they
had long forgotten that they had and help them realize that they
can utilize them in addressing their problem before the face-to-face
session.

4. Asking about the persons role model


facilitateschange
During the pre-session phone contact, as noted in Box 19.1, I sug-
gested that you ask your client about a role-model that might directly
or indirectly help them address their problem. Such a prompt may
help in two ways. First, the person may imagine how the person may
deal effectively with the problem and see that they can emulate them.
Second, they may imagine dealing with the problem because they
can experience the support of their role model as they do so. In both
cases, the person wants an opportunity to address their problem by
themself and choose not to attend the face-to-face session.

5. Noticing change helps the person see what is


possible and as a result is able to move on
Finally, when you ask a person to notice change between the phone
contact and the face-to-face session and they do so, they may real-
ize that they can change and choose to go it alone and decide not to
attend the third point of contact.
When a client exits the process between the phone contact and
the face-to-face session, then my advice is to ascertain the reason in
order to promote self-initiated change, support them in their decision
and remind them they can come back to see you again if they need
to do so in the future.

135
PRACTICE

In the next ten chapters I will discuss different facets of the face-
to-face session starting with issues with respect to beginning the
session. But first a word about making an appointment for the face-
to-face session. The face-to-face can be an intense experience for
clients and certainly there is a lot to get through, as you will see.
For this reason, I suggest when making an appointment with a cli-
ent for the face-to-face session that you suggest that they nominate
a time where they can give themself some time to focus their mind
before the session and some time to reflect after the session. I sug-
gest that they switch off their phone and other devices 30 minutes
before the session to focus on what they want to achieve and refrain
from switching these back on for at least 30 minutes after the session
to give themself a chance to reflect on the session (see Chapter 29).

Notes

1 Some SSI-CBT therapists, in addition, send their clients, by email attach-


ment, an informed consent form to be downloaded, signed and submitted
at the beginning of the face-to-face session.
2 I have presented my notes here in a form in which they may be read-
ily understood by readers and have improved the English expression.
The original notes were written much more in staccato form without due
regard for English expression because they were for my own use.

136
THE FACE-TO-FACE SESSION. 1: BEGINNING

20
The face-to-face session: 1: Beginning

The model of SSI-CBT presented in this book is based on four points


of contact. The face-to-face session is the third contact. I will begin
my discussion on the assumption that you are following the four
points of contact model and have had the pre-session phone contact.
While there is no set way of beginning a face-to-face session, here
are a number of suggestions.

Update since the phone session

Since SSI-CBT is about facilitating movement, one way of imple-


menting this is to ask the client at the beginning of the face-to-face
session for an update on their problem since the phone session. I
recommend doing this even if the phone session happened very
recently. If a change has occurred, then I suggest that you discover
what the person did to effect such change. This information will
help both of you to see that the client may be able to effect change
by doing more of what they did to bring about improvement. If the
person tried something new that did not effect change, it is impor-
tant that you discover what this was and to distance yourself from it
and use the ensuing discussion as a search for a new way of going
forward for the client based on your input as an SSI-CBT therapist.

Report on the notice change task

In Box 19.1 in Chapter 19, I outlined my pre-session phone contact


protocol. One question listed there was based on one originally devised
by Steve de Shazer (1985), Between now and our face-to face-session,

137
PRACTICE

I want you to notice the things that happen to you that you would like
to keep happening in the future relevant to the problem. In this way, you
will help me to find out more about your goal. If you have asked this
question, you could begin the session by finding out what changes(s)
the client has noticed. Thus you may ask questions such as:
So, what changes have you noticed since we spoke on the phone?

If the client reports a change, you could ask:


What did you think you did to set off this process?
What difference is that change making?
If instead of making that change before we met today it
happened after this session what would you think of the
value of this approach to single-session therapy?
However, if the client reports no change, you can proceed as
follows:
What are your best hopes from our meeting today?
If this meeting turns out to be useful where do you hope it
will lead you?

Report on homework

It may be that you suggested a task for the client to do before the
face-to-face session. If so, it is important that you enquire about what
happened when the person did the task and what the outcome was.
If the client carried out the task and reports an improvement in their
problem as a result, this will help you both to see clearly what the
person did to bring about the change and make sure that you build this
into any programme of change you may develop during the face-to-
face session. If the client carried out the task and does not report any
improvement, thank them for doing the task and note that they have
provided some important information concerning what isnt going to
help them and use this as a starting point for what may help them.
Finally, if the client did not carry out the task, gently enquire about

138
THE FACE-TO-FACE SESSION. 1: BEGINNING

the reason for this and use the information positively to orient the
session towards change.

Freda was asked by her SSI-CBT therapist at the end of their


pre-session phone contact to write a letter to her mother which
should not be sent. This task arose out of the discussion they
had in the phone call that Fredas main problem was lack of
assertion with her mother. The purpose of the letter was to
provide information about Fredas feelings and then for the two
of them to explore obstacles of self-expression in the face-to-
face session. It turned out that Freda only agreed to do this
task to please her therapist. The therapist apologized for not
realizing that this might happen and the resulting discussion led
them to agree that a need to please was what underlay Fredas
lack of assertion with her mother and other people (including
her SSI-CBT therapist!). This, then, became the focus for the
rest of the session with good results as evidenced in the three-
month follow-up session (see Chapter 30).

Matters arising from the email summary

I mentioned in Chapter 19 that you might send the client an email


after the pre-session phone contact which would summarize what you
discussed in the phone session. In this email, you might also suggest
issues that the client might like to think about before the face-to-face
session and perhaps even tasks they might like to consider doing.
Given this, you might like to begin the face-to-face session by mak-
ing reference to the email summary. Here are some ways of doing so:

What did you make of the email summary that I sent you?
Depending on the persons answer, pick up on the aspect that
best suggests a productive way forward and continue from there.
Has anything changed with respect to your problem after reading the
email summary? If so, what did you do to bring about that change?

139
PRACTICE

Did you find anything in the email summary particularly help-


ful/useful? If so, can you elaborate?

Here is how I began the face-to-face session with Eugene:

Beginning the face-to-face session: Eugene

Windy: Hello, Eugene, nice to meet you. Perhaps we can start


by me asking you if you have noticed any changes in the
problem since we spoke on the phone?
Eugene: Well, yes and no. I havent given any group presenta-
tions, but I am keener to address the problem after I
received your mail summary than before.
Windy: What was it about the email summary that led to you
feel keener about addressing the problem?
Eugene: It made me think of how I could apply the various ideas
in there to my problem.
Windy: What one idea do you think could prove the most useful
for you in this respect?
Eugene: I think there are two ideas that stand out for me if Im
allowed to choose two?
Windy: Yes, of course.
Eugene: The idea that my attitude is involved in my problem and
the importance of facing up to what I am afraid of.
Windy: You have just described the two central components of
the CBT approach. Does it make sense for us to look at
the role that your attitude plays in your problem first and
in doing so we can figure out how to help you form an
attitude that will help you to face up to the problem?
Eugene: Yes.

Once you have got the process of SSI-CBT process underway,


your next task is to create a focus for the session which is the subject
of the next chapter.

140
2: CREATING A FOCUS

21
The face-to-face session: 2: Creating a focus

One of the most important skills that you need to implement after you
have initiated the SSI-CBT process is to help you and your client to
create a focus for the session. Obviously time is limited in SSI-CBT
and you have up to 50 minutes to complete the process and therefore
there is very little time for unfocused conversation. Having said that
some clients are likely to feel nervous at the outset and a bit of general
talk, laced with some humour helps to put the client at ease. However,
once they are settled the creation of a focus is paramount.

What is a focus?

Definitions of the word focus emphasize the importance of cen-


trality (the centre of interest or activity) and clarity (the state or
quality of having or producing clear visual definition). Thus, what
you are looking for when you help your client to create a focus in
SSI-CBT is a concentration on a clear, central point. Let me illustrate
this from a vignette from one of my SSI-CBT cases.

WD: If we are to get the most out of this session we need to


focus on one clear issue or problem that you are looking
for help with.
Client: Well, I get anxious in all sorts of situations.

[I can proceed in two ways here. First, I could ask the cli-
ent to choose one such anxiety to focus on.]

WD: If you could choose one of these anxieties to concen-


trate on with me, an anxiety which if I could help you
141
PRACTICE

with would make coming for single-session therapy well


worth your while what would it be?

[Second, I might ask the client if there is an obvious


theme to these anxieties. This is the line I actually took in
the session.]

WD: As you stand back and look at these anxieties, can you see
a theme that links them?
Client: Well, I think they all involve me being judged by other
people in some way.
WD: So, would it be a good idea for us to focus on your anxiety
of being judged by other people throughout this session
so I can help you deal with this eventuality in more con-
structive ways?
Client: Yes, that would be a good idea.

One important thing to note about this interchange is that the


focus is either on one of the clients problems or the one theme that
links the clients anxieties together. In this book I will refer to this
selected problem/theme as the target problem/issue.

The focus: problem, solution or both

In solution-focused therapy (SFT), the focus is on the solution, not


the problem and if you integrate SFT into your work you will help
the person focus on the solution to their problem and not the problem
itself. The SSI-CBT can accommodate this stance. My own position
is more in line with traditional CBT and the focus I strive to create
includes the persons problem and their goal with respect to the prob-
lem. This is exactly what I did in the case vignette above where I
said, So, would it be a good idea for us to focus on your anxiety of
being judged by other people (the clients problem) throughout this
session so I can help you deal with this eventuality in more construc-
tive ways (my suggested way forward or goal).

142
2: CREATING A FOCUS

At this stage of the SSI-CBT process, it is not so important to be


very specific about the persons problem as you will want to define
this more specifically soon. Having said this, if you are presented
with an opportunity to define the problem specifically at the same
time as you are creating a focus, then take it, as doing so will save a
little time and, as you should know by now, time is at a premium
in SSI-CBT. The important issue about creating a focus with respect
to goal-setting is that you cover it and it is OK to be vague about it
at this stage. This is precisely what I did when I said to the client,
. . . so I can help you deal with this eventuality in more constructive
ways. Thus, a focus should include the fact that you will be helping
the client to achieve a goal and not so much what that goal will be.
You will do this when you come to define the clients problem more
specifically, which will help you set a specific goal in relation to this
defined problem.
Finally, let me be clear that creating a focus which just incorpo-
rates the clients problem without a corresponding goal is neither
good practice in ongoing CBT nor in SSI-CBT, as it gives you both
nothing to aim for. Thus, avoid doing so, if at all possible.

Keeping to the focus or changing it

Once you have created a focus, you need to help the person to keep
to that focus, unless there is a good reason to change it. The two
main good reasons to change a focus in the face-to-face session
once you have created it are as follows. First, it becomes clear that
the originally created focus was inaccurate. You may have made
what I call a false start in SSI-CBT and need to make a proper start
by creating a more accurate focus. Second, when keeping to the
original focus threatens the working alliance between you and your
client and you need to change focus to preserve this alliance. Of
course, changing an already created focus means that you have not
used time as productively as you could, but keeping to an inaccurate
focus is both wasteful of your remaining time and poor therapeutic
practice.

143
PRACTICE

Prepare the client for possible interruption


andinterruptwith tact

Some clients find it relatively easy to keep to a focus once it has


been jointly created and only need to be gently nudged back to that
focus when they stray from it. Others find it almost impossible to
keep to a focus and, hopefully, you would have realized this while
considering whether or not such people are suitable for SSI-CBT
and suggested ongoing rather than single-session therapy. There is
a third group who can keep to a focus, but need more than a gentle
help to do so. They need to be interrupted. There are two main issues
to be considered about interrupting a client who has strayed from the
focus and cant be nudged back to that focus. First, it is best to pre-
pare all clients for the possibility of interrupting them and in doing
so, it is good to provide them with a rationale for interrupting them
and to seek their permission to do so. Here is an example of what I
say in this respect:

WD: There may be times when I may need to interrupt you. The
purpose of me doing this is to help you keep to the focus we
have agreed and sometimes, being human, you may stray a
bit too far from that focus which means that we lose valu-
able time. So, if this happens, can I have your permission to
interrupt you?

My experience is that when you give a rationale for interrupting


a client and they give permission for you to do so, then interrupting
them causes minimum disruption. Indeed, a number of clients will
actively want you to interrupt them since they acknowledge that they
tend to go off track and welcome being brought back to the agreed
focus.
The second issue to be considered is your own attitude and comfort
level concerning interrupting a client. Some people new to SSI-CBT
are reluctant to interrupt a client because they think that it is anti-
therapeutic or rude. Concerning the first issue, I would argue that it
is anti-therapeutic not to interrupt a client in SSI-CBT since the time

144
2: CREATING A FOCUS

that you spend letting them talk away from the focus will, generally,
not lead to good results and will tend to prevent you from achieving
your joint purpose of helping them achieve what they came into SSI-
CBT to achieve. On the second point, as long as you do so with tact,
having explained the purpose of the interruption and sought permis-
sion to do so, it is hardly rude to interrupt your client. Rudeness in
this respect is when you interrupt a client (a) without tact, (b) without
presenting a rationale and (c) without having sought and being given
permission to do so.
Finally, if you are uncomfortable about interrupting clients. I sug-
gest that you interrupt them while feeling uncomfortable until you
can do so without discomfort. Doing role-plays with colleagues when
they play a client and you interrupt them will help in this respect.

Creating the focus: Eugene

Windy: So based on the email summary and your conclusions


from it, what problem do we need to focus on in this
session today?
Eugene: My anxiety about giving group presentations and my
attitude about giving them.
Windy: And what do you want to achieve?
Eugene: I want to change my attitude so I can give group presen-
tations rather than avoid them as I am currently doing.

There are a number of points to make about this exchange. First, it


is a little unusual for a client to feature their attitude and changing
their attitude in the creation of a therapeutic focus. Encouraging, but
unusual. Second, the problem and goal have been described loosely
and not properly formulated or defined in the first case or set in the
second case, which is acceptable for the creation of the focus. I will
discuss how to help you and the client understand their problem in
the next chapter.

145
3: UNDERSTANDING THE TARGET PROBLEM

22
The face-to-face session: 3: Understanding
the target problem
After you have helped your client to create a focus, the next step is
to help them do two things. First, help the person to state their target
problem (i.e. the one problem that they selected to address in SSI-
CBT) so that you can both understand it more clearly (which will be
the focus of this chapter) and second, help the person to set a goal
in relation to this target problem (which is the focus of Chapter 23).
If they have not yet had a chance to do so give your client an oppor-
tunity to express their target problem in their own words. When
they do so, I suggest that you listen to what they say using whatever
assessment framework that you employ and to use this framework
when clarifying what they are saying. This is likely to be some ver-
sion of the ABC framework that is commonly employed in CBT.
Problem understanding includes relevant information about the
problem that can be placed at A and at C. As we will see in the fol-
lowing chapter, goal setting includes the same data at A that appears
in the problem and more constructive responses at C.

Understanding the target problem

As I said above, understanding the problem involves finding out about


information concerning the persons responses at C to the adversity
that they actually faced or are thinking of facing at A. Normally in
CBT information about A and C is collected before the person is
helped to see that their B (problematic cognitions) are at the root
of the problematic responses at C to the adversity at A. For this
reason, I have left the topic of the assessment of B until Chapter 24.

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PRACTICE

Understanding responses at C

The main response systems you will want to understand in relation


to your clients target problem are emotional, physiological, behav-
ioural, and cognitive.

Emotional responses at C
In my experience, clients tend to bring eight problematic nega-
tive emotions to SSI-CBT. The ones that they readily nominate for
change are anxiety, depression, guilt and jealousy. They tend to be
ambivalent about changing anger, while shame, hurt and envy tend
to be a feature of some of their problems, but they need to be helped
to see this.

Physiological responses at C
Different people respond differently physiologically at C to adver-
sities at A, with perhaps the greatest variability in physiological
responsiveness being seen in anxiety. While people respond physi-
ologically to adversities they can then focus on their response which
then becomes an A, about which they may further disturb them-
selves. This phenomenon is known as a meta-problem and I will
discuss further later in this chapter.

Behavioural responses at C
In my view, you need to be interested in two types of behavioural
responses. The first type involves behaviours that are associated with
the emotional responses listed above. For example, when your cli-
ent experiences anxiety, they will tend to withdraw from the threat.
When I train people in SSI-CBT (WD), I suggest that they learn
the main ways people tend to act when they experience each of the
problematic emotions listed above (see Dryden, 2009). Whatever
approach to CBT you practise you may benefit from learning this
material.

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3: UNDERSTANDING THE TARGET PROBLEM

The second type of behavioural responses that you need to be


interested in involves behaviours that people engage that are designed
to protect them from the adversity. These include avoidance behav-
iours, safety-seeking behaviours, reassurance-seeking behaviours,
over-compensatory behaviours, the use of alcohol and drugs and
facing less aversive situations.
You need to discover which specific behaviours in their target
problem the person enacts in both types of behavioural response dis-
cussed above.

Cognitive responses at C
The ABC framework indicates that people disturb themselves at C
about the adversities in their life at A because of the views that
they take of these adversities at B. So far we have considered the
emotional, physiological and behavioural components of distur-
bance. The final component that I want to discuss involves cognitive
responses to adversity. These include the inferences people make
when they are disturbed which tend to be heavily skewed to the neg-
ative, the ruminations that people engage in when they are disturbed
and the way they process information when they are disturbed. In
addition, you need to understand the cognitions that people engage
in when they seek to protect themselves from the adversity. These
are the cognitive equivalents to avoidance, safety-seeking, reassur-
ance seeking and over-compensatory behaviours.
It is important to remember that you dont have time to be compre-
hensive in the data that you collect about your clients C with respect
to their target problem. However, you need the breadth of knowledge
to be able to discover the major C factors of their problem.

Understanding the adversity at A

Once you have understood the major components of your clients


disturbed response to the adversity in their target problem, you
need to understand the nature of this adversity. There are two major

149
PRACTICE

components of the adversity. The first is the situation in which the


problem occurred and the second is the aspect of the situation that
the person was most disturbed about. This is likely to be inferential
in nature. This latter component is likely to be the most important to
understand.

Situational A
I call the situation in which the adversity occurs, the situational A.
It is usually reflected in more descriptive accounts of the problem.
Thus, when Eugene says that he is anxious about giving group pre-
sentations, giving group presentations is the situational A.

Inferential A
In Chapter 4, I made the point that, if possible, it is important that
you help your client deal healthily with their adversity and I men-
tioned above these are likely to be inferential in nature. Also in
Chapter 4, I listed the main inferences associated with each of the
eight problematic emotions for which people tend to seek help. In
training people in SSI-CBT (WD) I suggest that they learn these
inference-emotion associations so that they search out the inferential
adversity when working with the main disturbed emotion involved
in the target problem. Whichever approach to CBT you practice it is
important that you become versed in the type of As that go along
with each of the Cs that your clients are likely to bring to SSI-CBT.

Identifying the adversity: the magic question


technique
There are many ways of assessing the inferential A in SSI-CBT.
However, one of my favourite methods is known as the magic ques-
tion technique (Dryden, 2001). Here is how to use this technique:

Step 1: Have the client focus on their disturbed emotional C (e.g.


anxiety).

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3: UNDERSTANDING THE TARGET PROBLEM

Step 2: Have the client focus on the situation in which C


occurred (e.g. about to give a public presentation to a group
of consultants)
Step 3: Ask the client: Which ingredient could we give you to
eliminate or significantly reduce C? (here, anxiety). (In this
case the client said: my mind not going blank). Take care that
the client does not change the situation (i.e. they do not say:
not giving the presentation)
Step 4: The opposite is probably A (e.g. my mind going
blank), but check. Ask: So when you were about to give
the presentation, were you most anxious about your mind
going blank? If not, use the question again until the client
confirms what they were most anxious about in the described
situation

Looking for the presence of a meta-problem


and deciding whether to make this the
target problem

In Chapter 3, I discussed the concept of the meta-problem.1 This


describes the uniquely human phenomenon whereby having dis-
turbed themself about an adversity at A, the person then focuses
on their response, an aspect of which becomes another adversity
for the person who then disturbs themself about this second prob-
lem. In ongoing therapy, you would deal with the meta-problem
before the original problem only if its presence prevented the
original problem being tackled both inside and outside therapy
and if the client could see the sense of doing so. In SSI-CBT,
where time is at a premium, in my view, it should only be tack-
led if it is, in fact, the clients main problem. If they realise that
it is, then fine, but if not, you need to provide the client with a
rationale for your viewpoint and why it should be the focus of
the work and therefore become the clients target problem. An
example of this is where the client experiences a lot of shame
about their problems.

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PRACTICE

Understanding the target problem: Eugene

Windy: So let me find out a little more about your anxiety about
giving group presentations. I asked you while we had
our phone session to imagine that you were going to
give a group presentation imminently. Did you do this?
Eugene: Yes I did.
Windy: What is it about giving such a presentation that you are
most anxious about?

[In the ABC framework that I use, A stands for adversity.


This includes the situations that people have problems
about (in Eugenes case the group presentations) and
what it is about these situations that they find aversive. I
am now going to try and find out what this adversity is.
Note that I am working with a specific future example
of the clients problem here. As I explained earlier, I am
doing so because this will help the client more easily put
into practice whatever they may learn from the SSI-CBT
process the next time they encounter the situation in
which they are likely to encounter their problem.]

Eugene: Well, I may get nervous and people may see this.
Windy: Which of those do you get most anxious about . . .
Getting nervous or people seeing you get nervous?
Eugene: Both the same.
Windy: Lets take these things one at a time. What anxious
meaning are you giving to getting nervous?
Eugene: I think it means that I have a defect.
Windy: And what anxious meaning are you giving to people
seeing you get anxious?
Eugene: That they also think that I have a defect.

[So Eugenes A is Giving a group presentation and


showing himself and others that he has a defect by get-
ting nervous and being seen to get nervous.]

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3: UNDERSTANDING THE TARGET PROBLEM

Windy: Now let me see what you do when you are anxious in
this situation.
Eugene: Well, I try to get out of giving them if I can.
Windy: So you avoid them. What if you cant avoid them?
Eugene: Well, I either do a lot of preparation and practice. Too
much, really.
Windy: So you over-prepare and over-rehearse?
Eugene: Yes.
Windy: Anything else?
Eugene: Well, just before I give a presentation, I have a few shots
of whisky to calm my nerves.
Windy: What about in the room, how do you try to hide your
symptoms?
Eugene: I give a PowerPoint and turn my back on the group and
talk to the screen.
Windy: Now when your anxiety has kicked in, what thoughts do
you have?
Eugene: I think that people are waiting for me to screw up.

Here is a summary of Eugenes problem using the ABC frame-


work that I use. You will note that I have divided the A into its
situational and inferential components.

A (Situational): Giving a group presentation


A (Inferential): I will be nervous which means that I have a
defect. The group will see that I am nervous and think I
have a defect
B (Belief ): Not assessed yet
C (Emotion): Anxiety
C (Behavioural): Avoidance (of A)
(If cant avoid A): Over-prepare and over-rehearse in advance
Take alcohol before going into the room
Hide from the group in the room
C (Cognitive): People are waiting for me to screw up

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PRACTICE

Generalizing from the target problem

I mentioned earlier in this book that one of the skills that the SSI-
CBT therapist needs to develop is to move, with facility, from a
specific focus to a general focus and back again, if necessary. In
this chapter, I have discussed how to identify your clients target
problem. Now would be a good time to enquire whether the problem
is experienced in contexts other than the one that frames the target
problem. Here is how I did this with Eugene.

Windy: So the main thing that you are anxious about with respect
to giving a group presentation is that if you get nervous
you will reveal to yourself and to others that you have a
defect. Is that right?
Eugene: Thats right.
Windy: Is this a problem for you in other situations?
Eugene: Yes. It occurs basically in any situation where the focus
is on me and where I may show some weakness.
Windy: And you get anxious about such situations?
Eugene: Yes, I try to avoid them if I possibly can.
Windy: So although our main focus will be on you giving group
presentations, is it worth us considering how you might
generalize what you learn about handling these presen-
tations to other situations where the focus is on you and
where you may reveal a defect or weakness to yourself
and others?
Eugene: That would be great if we could do that.

Having considered the issue of understanding the target problem,


in the next chapter, I will discuss setting goals, in general in SSI-CBT
and with respect to the target problem, in particular.

Note

1 Meta-problem here means the problem about the problem.

154
4: SETTING A GOAL

23
The face-to-face session: 4: Setting a goal

After you have helped yourself and your client to understand the A
and C features of their target problem, you are in a good position to
set a goal with respect to that problem. Here are some examples of
questions that you might ask:

What would you take away from the session that would make it
worthwhile?
What would you take away from the session that would give
you a sense that you could effectively deal with the issue?
What would you take away from the session that would help
you get unstuck?
Instead of responding to the situation or adversity with (name
the clients current problematic response) how would you like to
be able to deal with it?
Instead of responding to the situation or adversity with (name
the clients current problematic response) what would an accept-
able constructive response be for you?

The importance of setting a goal in response


totheadversity (inferential A) rather than in
responsetothe situational A

Often when people discuss their problems in therapy they talk about
their disturbed responses to the actual situations that they find prob-
lematic. As discussed earlier, I call these situations situational As.
Thus, when Eugene first told me what he wanted to focus on in SSI-
CBT he said that he was anxious about giving group presentations.

155
PRACTICE

When we looked further we found out what it was about giving


group presentations that Eugene was most anxious about revealing a
defect to himself and others by getting nervous. In the ABC frame-
work that I use, giving group presentations is Eugenes situational
A and revealing a defect to self and others is his inferential A. My
view is that Eugenes inferential A is his adversity.
If people tend to identify situational As when they nominate
their target problem, they do the same when discussing their goal
unless guided to set a goal with respect to their adversity (usually
their inferential A). You will probably have to give them a rationale
for providing such guidance which they need to accept before you
both proceed. I deal with this issue with Eugene as can be seen at the
end of the chapter.

Helping your client to construct healthy responses


to the adversity

Once your client understands the importance of setting a goal with


respect to facing their adversity, then your next task is to help them
to construct healthy responses to that adversity. This will serve as
their goal with respect to their target problem.
In my view, the best way to do this is to take the AC components
that you identified when working to understand the problem. The
A components were the situation in which the problem occurred
(the situational A) and what the person was most disturbed about
(the inferential A). In my view the inferential A is most often the
adversity. When setting a goal with the client, it is important to keep
these A components the same. Otherwise the person will not be
helped to deal with their adversity constructively. The C compo-
nents are the emotional, behavioural and cognitive responses to the
adversity. In helping the person to construct healthy responses, ide-
ally you need to help them identify alternative healthy responses to
each of the unhealthy responses in the three response categories listed
above, i.e. emotional, behavioural and cognitive. I have provided an
example of this at the end of the chapter from my work with Eugene.

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4: SETTING A GOAL

Healthy behavioural responses


Perhaps the easiest healthy responses to construct are behavioural in
nature. As I will discuss below, it is important, if possible, to help the
person nominate the presence of a healthy behaviour rather than the
absence of an unhealthy behaviour.

Healthy cognitive responses


When constructing healthy cognitive responses to the adversity, i.e.
responses that accompany emotions at C rather than those that
mediate (at B) responses to the adversity at A, a useful rule of
thumb is as follows. Healthy cognitive responses are balanced and
incorporate negative, neutral and positive features of A (e.g. some
people may judge me negatively for showing my nervousness, some
will be compassionate towards me and some wont even notice)
whereas unhealthy cognitive responses are highly distorted and
skewed to the negative (e.g. everyone will judge me negatively for
showing my nervousness).

Healthy emotional responses


As I discussed in Chapter 4, when your client comes to SSI-CBT
struggling in the face of an adversity, SSI-CBT provides you both
with an opportunity to deal constructively with that adversity. In
some forms of CBT, the emphasis is on helping clients to see that
their inferential As are distorted and that the thrust will be on help-
ing them by questioning these distorted inferences. While this stance
is often useful, it does not help your client to deal constructively with
adversity from their frame of reference. In addition, it is not incon-
ceivable that they may encounter situations where their inferences
turn out to be correct. Thus, while Eugene may at times distort real-
ity by assuming that people may think he has a defect if he reveals
being nervous while giving a group presentation, this may happen
and, as we will see, my approach is founded on the idea that he needs
to be helped to deal with this eventuality.1

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PRACTICE

When a person has a problem with an adversity, they usu-


ally experience a negative emotion. I call this negative emotion
unhealthy when it leads the person to get stuck, is associated with
a variety of unconstructive behavioural and cognitive responses
and discourages the person from facing up to and dealing construc-
tively with the adversity. When the person responds constructively
to the adversity they also experience a negative emotion. Why?
Because the A is negative and it is healthy to feel negative when
something negative happens. I call this negative emotion healthy
when it leads the person to get unstuck, is associated with a variety
of constructive behavioural and cognitive responses and encour-
ages the person to face up to and deal constructively with the
adversity.
Negotiating a healthy emotional response to an adversity can
often be quite difficult with a client since, people generally think
that such a response involves the diminution or absence of an
unhealthy negative emotion rather than the presence of a healthy
negative one. Also, in the English language we do not have terms
that clearly denote healthy negative emotions in a way that clearly
differentiate them from unhealthy negative emotions. Conse-
quently, it is important that you negotiate with your client terms for
both the unhealthy negative emotion that they experience in their
target problem and their healthy negative emotion which they will
experience if they reach their goal.

Negotiating obstacles to effective goal-setting


in SSI-CBT

Even though time is at a premium in SSI-CBT (an oft-repeated


refrain in this book!), it is worth taking your time helping your client
to set a realistic goal. In particular, there are a number of obstacles
to negotiate while effectively setting such a goal. Here are some of
the most common obstacles and brief guidelines concerning how to
respond if you encounter them in SSI-CBT.

158
4: SETTING A GOAL

When your client sets a vague goal


Your client may set a vague goal and, if so, it is important that you
help them to make this goal as specific as possible with respect
to their desired emotional, behavioural and if relevant, cognitive
responses to the adversity at A.

When your client wants to change A


Often your client may wish to change the A either the situational
A and/or the inferential A rather than changing their unconstruc-
tive responses to the A to those that are constructive. If this is the
case and A can be changed help them to understand that the best
chance they have to change A is when they are in a healthy frame
of mind to do so and this is achieved when their responses to this A
are constructive. So before they can change A, they need to change
their C.

When your client wants to change another person


When your clients target problem is centred on their relationship to
another person or group of people, then their goal may be to change
the other(s). You need to help your client to see that this goal is inap-
propriate as others behaviour is not under the direct control of your
client. However, attempts to influence others are under your clients
direct control and may lead to such behavioural change. As such,
they are appropriate goals. In such cases, however, it is often impor-
tant to help the client consider their responses when their influence
attempts do not work. Helping clients to deal constructively with
such failed attempts is often important in such cases.

When your client sets a goal based on experiencing


less of the problematic response
Often when asked about their goals in relation to the adversity at
A, clients say that want to feel less of the disturbed emotion that

159
PRACTICE

is featured in their target problem (e.g. less anxious). Many CBT


therapists may accept this as a legitimate goal, but it is problem-
atic in SSI-CBT (WD) for the following reason. REBT theory which
underpins SSI-CBT (WD), argues when a client holds a rigid belief
they take a preference (e.g. for acceptance) and turn it into a rigid
belief (e.g. I want to be accepted, and therefore I have to be). When
they hold a flexible belief they take the same preference and keep it
flexible by negating possible rigidity (e.g. I want to be accepted, but
it is not necessary that I am). In both the rigid belief and the flexible
belief the strength of the unhealthy negative emotion in the first case
and of the healthy negative emotion in the second is determined by
the strength of the preference when that preference is not met. The
stronger the preference under these circumstances the stronger the
negative emotion of both types. Thus, in SSI-CBT (WD), my goal is
to help the person experience a healthy negative emotion of relative
intensity to the unhealthy negative emotion rather than to encour-
age them to strive to experience an unhealthy negative emotion of
decreased intensity.

When your client sets a goal based on experiencing


the absence of the problematic response
You also need to be prepared when your client nominates the absence
of the problem as their goal (e.g. I dont want to feel anxious when
giving a talk). When your client says this, it is important to help
them see that it is not possible to live in a response vacuum and from
there you can discuss the presence of a set of healthy responses to
their adversity as their goal.

When your client sets as a goal a positive response


tothe situational A and bypasses the adversity
Another situation that may well occur when you ask a client for their
goal is that they may nominate a positive response to the situational
A while bypassing the adversity (usually the inferential A). For
example, if Eugene had taken this tack he would have said something

160
4: SETTING A GOAL

like, I want to become confident at giving group presentations. In


doing so he would have bypassed his dealing with adversity which
was revealing a defect to self and others by getting nervous. A good
response to Eugene would be to ask him how he could become con-
fident at giving group presentations as long as he regarded becoming
nervous as revealing a defect to himself and to others. By helping
Eugene to deal with this first and set an appropriate goal with respect
to his adversity, you will help him to take the next step and work
towards increasing his confidence about his performance. Taking
this approach is akin to a situation where you want to get to Wind-
sor from London by train, but the only way of doing so is to get to
Slough and change trains there to Windsor, as there is no direct train
from London to Windsor.

Setting a goal with respect to the target


problem: Eugene

Windy: Now that we are clear about what you are anxious about
and what some of the main features of your anxiety are,
lets discuss what you want to achieve from this session.
OK?
Eugene: OK.
Windy: What would you like to achieve by discussing this?
Eugene: I would like to be able to handle giving group presenta-
tions better.

[Note that when I ask an open-ended question about goals,


Eugene gives a general answer about dealing with his situ-
ational A rather than his inferential A. I now help him
to focus on his adversity (i.e. his inferential A) before
helping him to set a goal with respect to his adversity.]

Windy: Do you think that you will be able to do this if we first


deal with the issue of what you call your defects or if we
dont deal with them?

161
PRACTICE

Eugene: If we deal with them.


Windy: OK, let me first summarize. We have discovered that
what you are most anxious about with respect to giving
group presentations is considering that getting nervous
indicates that you have a defect and that if others see you
get anxious they will also think that you have a defect.
Correct?
Eugene: Yes.
Windy: As we have seen being anxious about such adversities is
not helping you, so what would be a more constructive
response to having a defect and being seen by others
seen to have the defect, assuming for the moment that it
is a defect and others will share this view?

[In other CBT approaches the therapeutic emphasis


may well be on helping Eugene to re-evaluate the
inferential meaning that he places on getting nervous
i.e. it is a defect and the inferential prediction about
others response to his nervousness, i.e. they will
regard his nervousness as a defect. In SSI-CBT (WD),
the initial focus is on assuming that inferences are
true temporarily so that evaluative meaning can be
identified and explored. This is more consistent with
REBT which is the main CBT approach that informs
SSI-CBT (WD).

Eugene: To not be concerned about it.

[As I indicated above, people often nominate a lack of


emotional response as a therapeutic goal and I discussed
the importance of not accepting this as a legitimate goal
for SSI-CBT.]

Windy: The only way I can help you do that is to have you
lie to yourself and believe that it doesnt matter if you

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4: SETTING A GOAL

have, or be seen by others to have, a defect. Is that


possible?
Eugene: No, I guess not.
Windy: So how about if I help you to have a negative emotion
about the prospect of revealing a defect, an emotion
whereby you dont feel you have to drink alcohol
beforehand, but can have water and where you can face
the audience during the presentation rather than hide
from them. And an emotion that will lead you to think
that most people arent waiting for you to screw up even
if some might be. How would that suit you?

[What I have done here is the following: (1) I have


indicated that it is healthy to experience a negative
emotion (C) in the face of an adversity (A) and thus
provided a realistic alternative to not feeling concerned;
(2) I have put forward the constructive behavioural
alternatives to the clients unconstructive behaviours
and (3) I have put forward a more balanced cognitive
response that accompanies concern as opposed to the
highly negatively skewed cognition that accompanied
Eugenes anxiety.]

Eugene: Well, that sounds more realistic, so yes.


Windy: OK, I would call this emotion concern without anxiety.
Does that make sense?
Eugene: Yes, so you distinguish between anxious and concern
without anxiety?
Windy: Yes, I do.
Eugene: OK.

Here is a summary of Eugenes goal using the ABC framework


that I use. You will notice that both the situational and inferential
components of A are the same in Eugenes problem as his goal. This
reflects my preferred practice of helping people deal constructively

163
PRACTICE

with adversity, whether real or imagined, before they try to change


the adversity if it is real and can be changed or question A if it is
inferential.

A (Situational): Giving a group presentation.


A (Inferential): I will be nervous which means that I have a
defect. The group will see that I am nervous and think I
have a defect.
B (Belief ): Not assessed yet.
C (Emotion): Concern, but not anxious.
C (Behavioural): Face A.
Drink water rather than alcohol before going into the
room.
Face the group in the room rather than hide from them.
C (Cognitive): Some people may be waiting for me to screw
up, but most wont be.

Generalizing from the goal

At the end of the last chapter, I mentioned that it is important for the
SSI-CBT to be able to move freely from a specific focus to a gen-
eral focus and back again. In this context, once you and your client
have understood the latters target problem and its A and C com-
ponents, it is important for you to check with your client whether
or not they experience the same problem in other contexts. If so,
it is important to help your client to see that they can generalize
any learning they derive from SSI-CBT with respect to their target
problem to these other situations and that you will help them do this,
if required. I then demonstrated how I did this with Eugene. If the
client has indicated that their target problem is an example of a more
general problem, then the same issue can be raised concerning their
goals. You can ask, therefore, if the goal that they have nominated

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4: SETTING A GOAL

with respect to their target problem is also what they would like to
aim for more broadly whenever they experience their more general
problem. Here is how I did this with Eugene.

Windy: So earlier we ascertained that your anxiety about giv-


ing a group presentation is a specific example of a more
general problem about revealing a weakness when the
focus of social attention is on you. The goal we have
set for this problem when it occurs in a group presenta-
tion context is for you to feel concerned, but not anxious
about revealing a defect to yourself and to others, but to
face the situation and to face the other people in the situ-
ation without finding ways to hide from them and to do
all this without using alcohol. Is that correct?
Eugene: Yes, it is.
Windy: Now, would that goal also hold when you think of facing
others situations when the focus is on you and you may
reveal a defect to self and to others?
Eugene: Yes, in general, it would be.
Windy: So while we keep our focus on handling giving group
presentations more constructively shall we look for
ways in which you could also achieve these same goals
in these other relevant anxiety-provoking contexts?
Eugene: That would be great.

Having helped your client to understand the A and C compo-


nents of their target problem and to set a suitable goal at C with
respect to the same A, in the next chapter, I will consider the topic
of helping your client to understand the problematic cognitions at B
that mediate between A and C.

Note

1 Assuming, of course, that Eugene sees the sense of doing so.

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5: IDENTIFYING THE CENTRAL MECHANISM

24
The face-to-face session: 5: Identifying the
central mechanism
Epictetuss famous dictum, People are disturbed not by things, but
by the views they take of them, has been put forward as a saying
that describes in a nutshell the role of cognition in the emotional
disorders. In the ABC framework, that most CBT therapists use,
B describes the cognitions that we hold about the adversity at A
that explain our responses to that adversity at C. As I explained in
Chapter 3, different approaches to CBT have different views about
the nature and importance of B in accounting for and treatment of
psychological disturbance. In CBT approaches which take the view
that problematic cognitions or meanings explain such disturbances and
need to be modified, the nature of such cognitions vary according to
the approach. Here is a partial list of these problematic cognitions:

negative automatic thoughts;


cognitive distortions;
dysfunctional assumptions;
irrational beliefs;
maladaptive schemas.

In addition to these verbal constructs, there are images to be taken


into consideration as well.
These problematic cognitions are what I refer to in the book as
the central mechanism as they tend to account for the problematic
responses that the person has made to the adversity in question.
If you are a CBT therapist who believes that it is important to
identify and deal with problematic cognitions by helping clients to
modify them then you will look for those cognitions which your
approach tends to prioritize and you will help your clients examine and

167
PRACTICE

change them using a variety of methods which need to be employed


in ways framed by the time restrictions of SSI-CBT.
If you are a CBT therapist who believes that it is your clients
engagement with these so-called problematic cognitions rather than the
presence of such cognitions themselves that is the problem (i.e. the cen-
tral mechanism), then you will find ways to encourage them to accept
these cognitions in a mindful way rather than engage with them or try to
eliminate them and thence to commit themselves to value-based action.
In this chapter, I will consider the issue of identifying the central
mechanism usually in the form of problematic cognitions and in the
next chapter, I will look at how to deal with them and help the person
to develop a more constructive central mechanism. The best way
that I can discuss the role of identifying and dealing with central
mechanisms in SSI-CBT is to show how I approach these two issues
in SSI-CBT (WD). While I do employ mindfulness and acceptance-
based techniques in my work, my approach to the two issues is firmly
in the modification-based camp.

Identifying the central mechanism (problematic


cognitions) in SSI-CBT (WD)

So far in the practice part of this book, I have discussed creating


a focus, and working with a target problem by understanding the
adversity at the heart of the problem (at A in the ABC framework)
and the persons responses to this adversity at C and setting a goal
with respect to this target problem.
The next step is for me to help my client understand the role that
cognitions play in (a) their target problem and (b) their goal with
respect to that problem. I will help the client identify specifically what
these cognitions are in the first case and what healthier cognitions
might be developed in the second case. I do this in the following way:

1. I review with my client what we know and what we dont know


as a result of identifying the A and C components of the target
problem and their goal respectively.

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5: IDENTIFYING THE CENTRAL MECHANISM

Windy: So lets review what we know and what we dont


know. We know that when you have to give a group
presentation you feel anxious about doing so. We also
know that what you are most anxious about in this situ-
ation is getting nervous which would reveal to you and
your audience that you have a defect. Is that correct?
Eugene: Yes, thats right.
Windy: We also know that you would much prefer not to have
such a defect and reveal it to others. Is that right?
Eugene: Yes.

[What I am doing here is making explicit the first


stage of my assessment of Eugenes beliefs. In
REBT theory a rigid belief and a flexible belief
have a common core, in Eugenes case his prefer-
ence not to have a defect and for others not to see
it. Please note that I have not yet challenged his
inferences that (1) getting nervous is a defect and
(2) others present will also see it as a defect. If I
need to do this, it will be after I have helped Eugene
to develop a flexible belief about these adversities.]

Windy: What we dont know yet is what your anxiety is


based on and what your emotional goal about this
adversity could be based on. So please help me out
here. OK?
Eugene: OK.

2. I then take the clients preference (which is common to both


rigid and flexible beliefs) and ask the client whether his target
problem is based on his rigid belief or his flexible belief.

Windy: So when you are anxious about giving a group pre-


sentation is your anxiety based on belief 1, that you
prefer not to have such a defect and for others not
to see it and therefore both these things must not

169
PRACTICE

happen or on belief 2, that you prefer not to have


such a defect and for others not to see it, but unfor-
tunately that does not mean that both of these things
must not happen?
Eugene: When I am anxious, my anxiety is based on the first
belief you outlined.

[What I have done here is to help Eugene see that


a problematic cognition is at the core of his prob-
lem and that this is expressed in the form of a rigid
belief. Please note that here I am guided by REBT
theory. Other CBT therapists will be guided by
whatever theory underpins their approach to CBT.]

3. I then ask the client how they would feel if they have a strong
conviction in the alternative flexible belief and connect this
belief with their goal.

Windy: And how would you feel if you had a strong convic-
tion in the other belief, that you prefer not to have
such a defect and for others not to see it, but unfor-
tunately that does not mean that both of these things
must not happen?
Eugene: Well, if I really believed it I would feel what you
called concern.
Windy: Which is what we agreed was the emotional goal
we would aim for.
Eugene: Thats right.
Windy: So can you see that when you take your preference
not to have the defect of getting nervous in group
presentations and for others not to see this defect
and you make this preference rigid you create feel-
ings of anxiety?
Eugene: Yes, I can see that.
Windy: And can you see that when you keep the preference
flexible you are concerned, but not anxious about

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5: IDENTIFYING THE CENTRAL MECHANISM

giving group presentations and the prospect of


getting nervous and others present seeing this and
thinking as you do that you have a defect?
Eugene: Yes, I can.
Windy: What do I need to help you do to work towards your
goal?
Eugene: To help me to believe the flexible belief.

In Table 24.1, I present a summary of Eugenes ABC assessment


for both his target problem and for his goal in relation to his problem.
Note again that his A is the same in both.

Table 24.1 Eugenes ABC assessment for his target problem and his goal

Target problem Goal


A (Situational): Giving a group A (Situational): Giving a group
presentation presentation
A (Inferential): A (Inferential):
(a) I will be nervous which means (a) I will be nervous which means
that I have a defect that I have a defect
(b) The group will see that I am (b) The group will see that I am
nervous and think I have a defect nervous and think I have a defect
B (Rigid belief ): I prefer not to B (Flexible belief ): I prefer not to
have such the defect of getting have such a defect and I prefer that
nervous and I prefer that others others dont see it, but unfortunately
dont see it and therefore both that does not mean that both of
these things must not happen these things must not happen
C (Emotion): Anxiety C (Emotion): Concern, but not
C (Behavioural): Avoidance anxious
(If I cant avoid A): Over-prepare C (Behavioural): Face A
and over-rehearse in advance Drink water rather than alcohol
Take alcohol before going into the before going into the room
room Face the group in the room rather
Hide from the group in the room than hide from them
C (Cognitive): People are waiting C (Cognitive): Some people may
for me to screw up be waiting for me to screw up,
but most wont be

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PRACTICE

4. At the end of a piece of work in identifying the central mecha-


nism in the form of problematic cognitions in my clients target
problem and the new central mechanism in the form of healthy
alternative cognitions in their goal, I then enquire if these two
sets of cognitions are also present in other contexts in which the
clients problem occurs and in which their goal is relevant. If I
have been accurate in my cognitive assessment, these two sets of
cognitions are generally present. In which case, I encourage my
client to look for these when dealing with the problem in these
other contexts.

In the following chapter, I will consider how I deal with the cen-
tral mechanism (in the form of problematic cognitions) that accounts
for the clients target problem.

172
6: DEALING WITH THECENTRAL MECHANISM

25
The face-to-face session: 6: Dealing with
thecentral mechanism
In this chapter, I will consider how to deal with the central mech-
anism in the form of problematic cognitions that account for the
clients target problem. Here, you will wish to use your preferred
CBT approach. If you hold to the view that these problematic cog-
nitions are best modified, you will use your preferred strategies,
mindful of the constraints on your time that SSI-CBT imposes. If
you believe that such cognitions need to be mindfully accepted as
a prelude to value-based action, you will use appropriate meta-
phors and in-session demonstrations to implement this strategy.
Or perhaps, you practise a mixed approach and consider that the
main issue is when to encourage clients to modify their problematic
cognitions and when to encourage them to accept these cognitions
in a mindful way. In what follows, I outline and demonstrate my
approach to the issue.

Dealing with the central mechanism (problematic


cognitions) in SSI-CBT (WD)

Once the client has understood the connection between their cen-
tral mechanism in the form of problematic cognitions (in this case a
rigid belief ) and their target problem and between their new central
mechanism in the form of healthy cognitions (in this case a flexible
belief ) and their goal, the next step is to help them to stand back
and examine both sets of cognitions. In SSI-CBT (WD), my task as
therapist is twofold. First, I need to help my client to understand why
their rigid and extreme beliefs are problematic for them and second,

173
PRACTICE

I need to help them to understand why their alternative flexible and


non-extreme beliefs are healthy for them. Here are the steps I tend
to take.

1. First, I take both beliefs at once and ask my client questions


about the empirical status, the logical status and the pragmatic
status of each. I also ask them their reasons for their answers.

Windy: First, let me help you to stand back and consider


both beliefs so that you can make an informed deci-
sion about which one is best for you. OK?
Eugene: OK.
Windy: So just to remind you, your rigid belief is, I prefer
not to have such the defect of getting nervous and
I prefer that others dont see it and therefore both
these things must not happen and your flexible
belief is, I prefer not to have such a defect and I
prefer that others dont see it, but unfortunately that
does not mean that both of these things must not
happen. Is that right?
Eugene: Thats correct.
Windy: Now which of these beliefs are more consistent with
reality and which is less consistent with reality?
Eugene: The rigid belief is not consistent with reality while
the flexible is.
Windy: Why?
Eugene: Well, just because I demand that I dont get nervous
and that others dont consider this to be a defect
doesnt mean that these things wont happen. When
my belief does not demand this it matches reality
better.
Windy: Which belief is sensible and which isnt?
Eugene: My rigid belief is nonsense because it is magical. It
implies that I can stop people from thinking that I
have a defect just because I demand this. My flex-
ible belief is not magical and therefore sensible.

174
6: DEALING WITH THECENTRAL MECHANISM

Windy: Which belief will have better results for you and
which will have worse results?
Eugene: As you have helped me see, my rigid belief will
lead to me being anxious and that wont help me
give good group presentations. But my flexible
belief will lead me to be concerned and that will
help me to improve my group presentation skills.

2. I then ask my client if they have any doubts, reservations and


objections about weakening their rigid belief and strengthening
their flexible belief and I deal with any misconceptions they may
reveal in their response.

Windy: Do you have any doubts, reservations or objections


to weakening your rigid belief and strengthening
your flexible belief?
Eugene: Well, if I do this then I will be more likely to give
a group presentation and more likely to expose
myself to others seeing me nervous.
Windy: And then they may think you have a defect.
Eugene: Yes.
Windy: And if they did what would that mean to you?
Eugene: That I am defective.
Windy: As a person?
Eugene: Yes.
Windy: OK. Shall we stand back and consider that idea?
Eugene: OK.
Windy: Do you have any children?
Eugene: No, but I plan to have one or two one day.
Windy: So would you sit your children down and teach
them to regard themselves as defective if they
reveal their nervousness to others and they think of
them as revealing a defect?
Eugene: No, of course not.
Windy: Why not?
Eugene: Because I love them.

175
PRACTICE

Windy: So are you saying that you would privately think of


them as defective, but out of love you would teach
them that they werent?
Eugene: No, I am not saying that.
Windy: So help me understand?
Eugene: I would teach them that if they revealed their ner-
vousness to others and these people considered them
doing so as a defect then they werent defective.
Windy: What attitude would you encourage them to take
towards themselves under these circumstances?
Eugene: That they were normal human beings who got ner-
vous in public.
Windy: And would you encourage them to hold this atti-
tude towards themselves if others considered them
defective for having a defect?
Eugene: Yes, I would.
Windy: Why?
Eugene: Because it would be true and . . . Oh the penny drops
. . . (laughs) . . . and sensible and helpful for them.
Windy: You know what I am going to ask you now?
Eugene: If I would teach my children to regard themselves
as normal human beings even if others regard them-
selves as defective for getting nervous, why cant I
develop this attitude to myself?
Windy: Exactly. Why cant you?
Eugene: I can and I will.

3. My next step is to encourage my client to see that the next time


they encounter their adversity, they will begin to think in prob-
lematic ways, but can respond to this. Thus, their first response
is to be expected, but it is how they respond to this first response
that is important (see Chapter 12).

Windy: I think that it is important that you understand that the


next time you consider giving a group presentation
then you may well begin to get anxious because you

176
6: DEALING WITH THECENTRAL MECHANISM

will begin to think in the same rigid way that you have
done before. It is important that you dont get discour-
aged by this. It is a function of habit and habits can be
changed. So when this happens, respond by reminding
yourself of your flexible belief. Is that clear?
Eugene: Yes, it is.

4. After I have helped my client to examine their rigid and/or


extreme beliefs, on the one hand and their flexible and/or non-
extreme beliefs, on the other, dealt with any doubts, reservations
and objections they have expressed and made the point about the
importance of their subsequent response to their first response,
I ask them to summarize the work we have done so far. I prefer
to do this rather than summarize the work myself at the point
because I am mindful that the client will be taking away what
they have learned rather than what I have shown them.

Windy: So why dont you summarize what you have learned


so far about dealing with your anxiety problem.
Eugene: Well, first you showed me that the rigid belief I held
about having and showing a defect when giving a
group presentation explained my anxiety and if I
wanted to be concerned, but not anxious about doing
so, I needed to develop and strengthen a flexible belief
about having and showing a defect. You also helped
me to see that I could see myself as a normal human
being and not a defective one even if others think I am
defective and I never thought about this before.
Windy: And the point about your initial response to adversity?
Eugene: That it is a matter of habit and that when it happens
that it is important to respond to it.

5. I then suggest to my client that they can use similar strategies in


examining their rigid and extreme beliefs, on the one hand and
their flexible and non-extreme beliefs, on the other when deal-
ing with their problem when they encounter it in other contexts

177
PRACTICE

and when they respond to their rigid and extreme beliefs in these
contexts. In this way, they can generalize their learning.
6. My next step is to encourage my client to step back and examine
their inferential A, if it is clear that it may be distorted. This is
usually done after I have helped the client to begin to deal with the
inferential A and to that effect, I encourage the client to assume
temporarily that this A is true. Sometimes, however, it tran-
spires that the client does not respond well to my strategy of helping
them to deal constructively with the adversity. In which case, I will
help them to examine the adversity instead. In my work with Eugene
as I have shown, I first helped him to deal constructively with his
inferential A that getting nervous meant that he had a defect which
he would also reveal to others. Then I did the following:

Windy: So far we have assumed that getting nervous when


giving a group presentation is evidence of a defect,
but lets stand back and look at that. OK?
Eugene: OK.
Windy: If a very good friend told you that they got nervous
while giving a group presentation, would you tell
them that they had a defect?
Eugene: No.
Windy: Would you privately think that they had a defect,
but wouldnt tell them?
Eugene: No, I would not think that.
Windy: So, if you did not think that them showing nervous-
ness proved that they had a defect, what would you
think that it meant?
Eugene: That they had an anxiety issue.
Windy: Whats the difference between a defect and an anxi-
ety issue?
Eugene: An anxiety issue is not a pejorative term, while a
defect is.
Windy: So if your good friend showed that he was nervous
while giving a group presentation, he would have an
anxiety issue and not a defect, while if you showed

178
6: DEALING WITH THECENTRAL MECHANISM

nervousness in the same situation, you would have


a defect?
Eugene: Yes, I see what you mean.
Windy: You see that you have a choice: to see your nervous-
ness as an anxiety issue or as a defect.
Eugene: Yes, my first instinct is to see it as a defect . . .
Windy: And when you stand back and think of your friend?
Eugene: Then I can see that I have an anxiety issue and not a
defect.
Windy: What difference would that make to you?
Eugene: I wouldnt feel so ashamed of getting nervous.
Windy: So you have two ways of dealing with your shame.
First, to be flexible in your attitude about having
and showing a defect and second to see that getting
nervous isnt really a defect.
Eugene: Which is the best approach?
Windy: My suggestion is that you first develop and rehearse
a flexible belief about the defect and then to ques-
tion whether or not it really is a defect.

7. Finally, I encourage my client to use mindfulness-based techniques


under certain conditions. Thus, when a client has spent some time
modifying a problematic cognition, be it a rigid and/or extreme belief
or a distorted inference, that problematic cognition may linger in the
persons mind after that work has been done. Rather than encour-
aging my client to use this continuing presence as a cue to renew
modifying that cognition, I suggest that they accept the presence of
that thought in their mind without engaging with it or attempting to
get rid of it and to get on with whatever they would be doing if the
thought was not in their mind. I see cognitive modification as akin to
spending time in a gym. It is time limited and the benefit will accrue
overtime. As with the gym, rest periods are essential.

In the next chapter, I will discuss the importance of making an


impact in SSI-CBT so that the work you do with the client is mean-
ingful for them.

179
7: MAKING AN IMPACT

26
The face-to-face session: 7: Making an impact

You may recall that in the pre-session phone contact, I outlined


a number of areas where you need to gather information to assist
you in helping your client to get the most out of the SSI-CBT pro-
cess. The purpose of getting this information is to make SSI-CBT
an impactful experience for your client. While I have chosen to put
this material here in that it is often when the client can under-
stand the importance of developing new meaning in relation to the
adversity at A that you can concentrate on increasing the impact of
such understanding this issue is relevant throughout the process.
Here is a list of strategies that may help make the SSI-CBT process
more impactful for your clients. Please bear in mind that one well-
chosen strategy is likely to be more helpful than trying overly hard
to increase the impact of therapy using several strategies in a short
period of time. In SSI-CBT here as elsewhere, often less is more.

Find and use something that really resonates with


yourclient while helping them

It is difficult to know what is going to resonate with your client with


respect to helping them deal with their target problem. Here are a few
tips, though. First, you need to listen carefully to the language that
your client uses in their contacts with you. If they use certain words or
phrases frequently then this may be one indication that such language
is meaningful to them, particularly if it is accompanied by affect.
The same applies to any recurrent imagery to which they may refer.
Second, watch carefully to see if your client demonstrates engage-
ment with the language and concepts that you use in the sessions.
Such engagement may be marked by affect, an increase in attention,

181
PRACTICE

forward leaning and the repetition of language that you may use. How
you use any of this material will vary from client to client, but the best
way of doing so will be to promote cognitive change which will be
facilitated if the client is emotionally engaged in this process.

Structure your interventions in ways that reflect


howyour client has been helped and has helped
themself in the past

During the pre-session phone conversation, I suggested that you find


out what experiences your client has had in being helped and helping
themselves both in general and, more specifically, with respect to their
target problem. Then, you can use these helping principles and self-
helping principles to facilitate change with respect to this problem.

Eugene indicated that exposure to threat and tolerating


discomfort while he did so helped him with a problem earlier
in his life. Consequently, I used a number of opportunities to
remind him of his successful application of these principles
and helped him to see how he could use them while tackling
his target problem. In addition, I showed Eugene how he could
rehearse his flexible and self-accepting beliefs prior to giving
a group presentation and to hold these beliefs in mind while he
was in the situation.

Make use of your clients strengths

When you know what strengths your client considers they have you
can make reference at judicial times in the SSI-CBT process to these
strengths in order to make their self-change efforts more meaningful
and therefore more impactful.

When Eugene expressed a doubt about his capability to apply some


of the ideas that we discussed in the face-to-face session, I reminded

182
7: MAKING AN IMPACT

him that with determination (his stated strength) he may surprise


himself concerning what he could achieve. He seemed to resonate
with this way of linking determination as a response to such doubt.

Refer to your clients role model or to someone


who has been helpful in the clients life

Making reference to your clients selected role model or someone who


has been helpful to your client can galvanize your client, particularly
when they appear to be flagging. What is more important is helping
your client keep the person in mind after the face-to-face session when
putting into practice what they have learned in the session.

Eugenes selected his paternal grandfather as someone who


might be influential in the SSI-CBT and pointed to a helpful
saying that he associated with his grandfather, namely, What is
very bad now, will not seem so bad in the morning. This phrase
nicely encapsulates the non-extreme belief known as a non-
awfulizing belief and I encouraged Eugene to use a version of it,
should he encounter people who did regard his nervousness as a
defect: It might seem awful at the time if people thought that my
nervousness was a defect, but it would not seem so bad the next
day. Eugene said that if he imagined his grandfather saying this
to him with his arm placed around Eugenes shoulder that this
would be particularly impactful and I encouraged him to do so.

Utilize your clients learning style

The more you can utilize your clients learning, the more likely it is
that they will derive benefit from the SSI-CBT, assuming that they
relate to the ideas that you have helped them develop.

Eugene said that he learns best by giving himself some time to


think things through and particularly disliked being rushed.

183
PRACTICE

Although it may seem that this would pose a particular challenge


given that time is at a premium in SSI-CBT. However, I encouraged
Eugene to take his time at various points in the process and the
time he devoted to doing so was, in my opinion, well spent since
he appeared to be more involved in the process at the end of each
period of reflection. He also came up with a few reservations
about the usefulness of flexible beliefs that revealed some
misconceptions about this concept that I was able to address and
once Eugene took his time to digest my points he became more
committed to the constructiveness of flexibility of belief.

Utilize the visual medium as well as the


verbal medium

CBT is classified, correctly, as a talking therapy and as such there is a


lot of verbal communication between client and therapist. However, to
enhance the impact of SSI-CBT, it is useful sometimes to present visual
representations of verbal concepts especially for those clients whose
learning is enhanced by the visual medium. Figures 26.1 and 26.2 present
two examples of such visual representations that I use in SSI-CBT (WD).

Rigid Belief

...and therefore it must occur


Whats Important

Its important to me that


x occurs...
Flexible Belief

...but regretfully it doesnt have


to occur because I want it to

Rigid Belief vs Flexible Belief

Figure 26.1 Rigid belief vs flexible belief

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7: MAKING AN IMPACT

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Figure 26.2 The Big ILittle i technique

In Figure 26.1, I show how I teach visually the distinctions


between flexible and rigid beliefs. As shown, both are based on what
the person deems important. In a rigid belief the person holds that
what they deem important must exist and in a flexible belief, the
person acknowledges that they do not have to get what they deem
important to them.
In Figure 26.2, I present the Big I-Little i technique which shows
that the Big I, which represents a person, comprises a myriad of aspects
185
PRACTICE

represented by little is. It shows that a person cannot be defined by


any of their parts.

Refer to your clients core values to promote change

The reason that I suggest that you discover your clients core values
during the pre-session telephone contact is so that you can make use
of them to help your client to connect their goals and goal-directed
activities to their values. For a client will probably strive more per-
sistently towards a goal when it is underpinned by a core value than
when it is not.

I discovered during the pre-session telephone contact that


Eugenes stated core value was honesty. I referred to this value
initially to create a state of dissonance in Eugene who by hiding
his defect was not taking an opportunity of being honest with
others in the sense of showing them that he was a person who
got nervous when giving a group presentation. He could resolve
this dissonance either by honesty deciding to show his defect
while rehearsing the flexible and self-acceptance belief that he
constructed or by realizing that by deciding not to do this he was
not being true to his core value. He decided to take the former path.

Use humour judiciously

The use of humour in therapy has attracted a range of viewpoints


amongst practitioners (e.g. Lemma, 2000). My own view is that it
has the potential to be useful in increasing the impact of SSI-CBT.
This is especially the case when:

the client shows that they have a sense of humour;


the humour is directed affectionately at some aspect of the cli-
ent, but not the client themself;
the client can laugh at themself;

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7: MAKING AN IMPACT

the humour has a therapeutic message that can be accurately


articulated ideally by both client and therapist;
that message can be used by the client in the service of the cli-
ents goals.

However, humour has the potential to be harmful and it is impor-


tant that if you use humour, you pay attention to the clients response
and seek feedback. It may also be useful to ask the client at the outset
whether therapist use of humour would be welcomed.

Consider using self-disclosure

Like therapist humour, therapist self-disclosure has the potential to


be very useful in increasing the impact of SSI-CBT for some clients,
but it is not universally welcomed by clients. If you want to share a
personal experience that has a therapeutic message for the client it is
probably wise to alert the client to your intention and ask for permis-
sion before doing so.
Therapist self-disclosure tends to be therapeutic, therefore, when:

it is wanted;
it shows that the therapist has had a similar problem, but is not
ashamed about admitting it to self and to others;
it shows the therapist is equal to the client in humanity;
it clearly indicates what the therapist did to deal constructively with
their problem which may be relevant to the client. It thus has a
therapeutic point that may be able to be utilized by the client in
addressing their target problem and in working towards their goals.

Even if the client has given permission for the therapist to share
their experience it is useful to get feedback concerning both its use
and what the client has taken from the disclosure.

Having obtained his permission, I told Eugene about how I dealt


with my anxiety about speaking in public since it was similar

187
PRACTICE

to his anxiety about giving group presentations. In particular,


he found it useful when I told him that I accepted myself as a
fallible human being for revealing what I thought of at the time
as a weakness and how doing so helped me to address the issue.
He said that it gave what we were discussing more face validity
and personal relevance.

Use a range of techniques to increase impact, but


construct your own

There are a number of techniques that you can use to increase impact
in SSI-CBT. In using them I do recommend that you rely on your
own creativity rather than the creativity of others in increasing
impact. Something may occur to you in your work with a client that
may hit the spot that has never been used before and may never be
used again. Given the specific context in which the bespoke inter-
vention arose it is more likely to be impactful than employing off
the peg techniques that others have used that might be relevant to
particular clients. The bespoke rather than off the peg use of imag-
ery, metaphors and stories is particularly important in this regard.

Help your client to develop a brief, memorable


andimpactful version of their healthy thinking

One of the problems I have had to wrestle with in SSI-CBT (WD) is


how to help the client use a flexible and/or non-extreme belief in the
situation in which they need to use it, i.e. facing an adversity. You
will remember that I discussed flexible and non-extreme beliefs in
Chapter 3. If you review that material, you will see that both flexible
and non-extreme beliefs tend to be wordy. To increase the impact of
these beliefs and to help clients to use them when facing adversities,
my practice is to help them to develop a version of the healthy belief
that reflects its meaning but that is brief, memorable and meaningful.
I encourage clients to make a note of this statement and even to use it

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7: MAKING AN IMPACT

as a screen saver on their smart phone so they can quickly refer to it


when needed.

I helped Eugene to develop the following brief, memorable and


impactful version of his healthy belief: A defect proves Im
human not defective. I dont have to hide it.

In the following chapter, I will discuss how to help your client


to implement their learning from SSI-CBT both inside and outside
sessions.

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8: ENCOURAGING THE CLIENT TO APPLY LEARNING

27
The face-to-face session: 8: Encouraging the
client to apply learning inside and outside
the session
As in other CBT-based therapy formats, it is important that you
help your client to apply what they learn from SSI-CBT, but in this
approach you only have two shots at doing so. Your first opportunity
is when you ask your client to engage in an in-session task and your
second is when you encourage them to think about how they might
apply this learning in their life.

Helping the client apply learning inside the session

If you practise CBT where cognitive modification prominently fea-


tures, when you help your client apply what they have learned so
far from the SSI-CBT process in the session, you are looking for an
opportunity where they can practise their new helpful cognition and
act in ways that support its development. In my view there are basi-
cally three ways of doing this: (a) role play; (b) two-chair dialogue
and (c) imagery. In addition to providing an opportunity to practise
new ways of thinking and behaviour, these methods also serve to
increase the impact of SSI-CBT for your client (see Chapter 26)

Role play

There are a number of ways in which you might employ role play
in SSI-CBT to facilitate client learning. Here are some of the most
common:

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PRACTICE

1. You play a person in your clients life (e.g. a boss) and your client is
themself communicating to the other person having first got into a
healthy frame of mind which you have already helped them to develop.
2. You play the client and the client plays the other person in the above
scenario. This can be used when the client has found being themself
difficult in the role play. Having modelled healthy communication
and, if possible, the healthy thinking that underpins such behaviour,
you switch roles and the client can be themself again.
3. You play the unhealthy thinking part of the client and the client
speaks from their healthy thinking part and the purpose of the
resultant dialogue is for the client to strengthen their conviction
in their healthy thinking.
4. You play the healthy thinking part of the client and the client
speaks from their unhealthy thinking part. The purpose of the
resultant dialogue is for you to demonstrate ways of respond-
ing to unhealthy thinking to which the client has struggled
to respond when they spoke from their healthy thinking part.
Roles are then reversed to enable the client to gain experience in
responding effectively to unhealthy thinking.

Two-chair dialogue

In two-chair dialogue, the client switches between chairs in com-


municating with another person the client plays both parts or
with another part of themselves. Again the ultimate purpose of such
dialogue is for the client to gain experience of acting constructively
while rehearsing healthy thinking. I recommend Kelloggs (2015)
innovative work on transformational chair-work in this context.

Imagery

In using imagery, you encourage your client to imagine that they


are facing in the present an adversity which features in their target
problem and in doing so they imagine themself thinking healthily

192
8: ENCOURAGING THE CLIENT TO APPLY LEARNING

and then acting constructively. Because, in most cases, when your


client faces the adversity in reality they will first think unhealthily
and then respond to such unhealthy thinking with healthy thinking, I
recommend that you suggest that your client builds this process into
their in-session imagery. Otherwise they may get discouraged when
they find that their first thinking response to the adversity in real life
is an unhealthy one.
If you practise CBT where mindful acceptance of cognition pre-
dominates rather than its modification, then you will employ a range
of methods to help your client develop their skills in this area (see
Harris, 2009).

I encouraged Eugene to use imagery towards the end of the


face-to-face session in the following way: Close your eyes and
imagine that you are about to give a group presentation and
have begun to feel anxious because you think that you may get
and show your nervousness and think that this means you have
and are seen to have a defect. Now see yourself remind yourself
that A defect proves Im human not defective. I dont have to
hide it. Hold that belief in mind as you see yourself give the
presentation with due unanxious concern.

Helping the client apply learning outside the session

In a sense the most important part of the SSI-CBT process is one


over which you, as therapist, have no control. This is where your
client chooses whether or not to implement what they have learned
in the process to their life when the main part of the process ends.1
If they choose to do so, you will not have the opportunity to review
with them what they did until the follow-up session which is nor-
mally held three months after the face-to-face session. This is what
clearly delineates SSI-CBT from ongoing CBT. In the latter, your
client would be expected to do regular negotiated homework
assignments. You would review what they did each week and the
continuity of the execution of such tasks is what largely determines

193
PRACTICE

the outcome of ongoing CBT. In SSI-CBT, while what the client first
decides to do to implement their learning is important, what perhaps
is more important is the realization that they need to commit them-
selves to ongoing implementation.
From a cognitive modification perspective, this implementa-
tion should ideally reflect the following principles, expressed here
directly to the client:

Use a brief and memorable version of your healthy thinking.


Your behaviour should be consistent with the healthy thinking
that you wish to develop.
You should have your healthy thinking in your mind before act-
ing on this thinking.
Practise thinking healthily and acting constructively while fac-
ing the adversity listed in your target problem.
As you face your adversity, you may find yourself slipping back
into your old pattern of unhealthy thinking. This is normal and
respond to it with your healthy thinking when this happens.
You will experience discomfort during this whole process of
change. Expect this and tolerate it. Remind yourself that it is in
your long term interests to do so.
If necessary, rehearse what you plan to think and do in your
minds eye before you do so in real life.
Recognize that you may be tempted to keep yourself safe while
facing your adversity. It is best not to act on this urge. If you do
so, you wont help yourself in the long term.
Commit yourself to regular practice of your healthy thinking
and the behaviour that supports it.
If you keep practising, your feelings will eventually change.
Look for ways of generalizing your learning from the adversity
listed in your target problem to other related adversities.

How many of these principles you will want to discuss with your
client will depend on what your client wants to achieve and what
they can usefully digest. You may want to give your client the above
list as a handout with instructions to focus on one principle at a time.

194
8: ENCOURAGING THE CLIENT TO APPLY LEARNING

From the perspective of CBT based on mindfulness and accep-


tance principles the emphasis will be on helping the client to act in
value-based ways while acknowledging the presence of troublesome
cognition and emotion without engaging with them or attempting to
eliminate them.

Eugene resolved to give a group presentation every week while


rehearsing the short form of his flexible self-acceptance that I
discussed in the previous chapter: A defect proves Im human
not defective. I dont have to hide it. He also agreed to use
imagery rehearsal, as also described in that chapter. Finally,
he thought that it would also be useful if he then reminded
himself that getting nervous is a problem not a defect after he
had practised thinking healthily about having and being seen to
have the so-called defect (see Chapter 25).

In the following chapter, I will consider the topics of summariz-


ing, tidying-up loose ends and planning for the future.

Note

1 There is still, of course, the follow-up session to be held, which I will


discuss in Chapter 30.

195
9: SUMMARIZING

28
The face-to-face session: 9: Summarizing,
tidying up loose ends and the clients
commitment to the future
After you have discussed the important issue of how your client is
going to apply what they have learned from the SSI-CBT process to
relevant situations in their life, it is important that you ensure that
the client leaves the process with an accurate understanding of what
went on in the process and what they have learned from it. Also, it
is important that you deal with any unfinished business from the cli-
ents perspective and end the process on a positive and encouraging
note.

Summarizing

The purpose of summarizing what went on between you and your


client in the SSI-CBT process is to enable the client to leave with
an accurate understating of what went on, what they have learned
and, most importantly, what they plan to do in implementing this
learning.

You, as therapist, provide the summary

If you, as therapist, summarize, you should cover the following:

the reason your client sought therapy;


the understanding that you both arrived at concerning the cli-
ents target problem and what accounted for the problem;

197
PRACTICE

the goal that the client set and what the client needs to do to
achieve the goal;
a review of the resources that the client can bring to the process
of working towards the goal;
what the client needs to do to achieve the goal.

My preference is to have the client provide the summary (see


below), but if I had taken the lead in summarizing the work that I did
with Eugene, this is what I would have said:

The reason that you sought my help was because you were
anxious about giving group presentations. As we looked
further, we found that you were anxious because (a) you
thought that getting and showing you were nervous meant
that you were revealing a defect to yourself and others and
(b) because you believed that you mustnt have and be seen
to have a defect and that you are defective if these things
happen. Your goal is to feel concerned, but not anxious
about having and being seen to have a defect and the way
you can do that is to give group presentations regularly and
rehearse your flexible and self-acceptance beliefs about
the having and being seen to have the defect. Also you can
question whether getting nervous and showing it while
giving group presentations is evidence of having a defect
or having a problem. To help you achieve your goals you
have determination and your core value is honesty which
will help you reveal yourself as you are while giving group
presentations and rehearsing your healthy beliefs.

Once you have provided your summary, ask your client for
feedback and modify your summary accordingly. After this, you
might ask your client to make notes about your agreed summary,
although if you record the interview and provide a transcript for
your client (see Chapter 29), the summary will be available in both
media.

198
9: SUMMARIZING

Your client provides the summary

Having your client provide the summary enables them to draw


actively on their own understanding of the process and yields impor-
tant information concerning what they are likely to take away from
SSI-CBT. Once the client has provided the summary, you may then
prompt the client with those points above that they have not covered
and you think it is important to get covered. Here is how Eugene
summarized the process:

I came to you because I considered getting nervous while giving


group presentations meant that I had and was showing a defect.
You helped me see that it was my rigid belief about this that was
the problem and you helped me develop the idea that a defect
proves Im human and not defective and I dont have to hide it.
Thinking this way while I give group presentations will help me
solve the problem.

[On being prompted concerning what healthy negative emo-


tion he would feel about having and being seen to have the defect,
Eugene responded that he would feel concerned. Also when asked
what resources he could use to achieve his goal, Eugene mentioned
perseverance and being open about himself which I regarded as
being synonyms for what he said originally i.e. determination and
honesty.]

Dealing with loose ends

In my opinion, it is important for your client to leave the face-to-


face session with a sense of completeness about the process. Thus,
it is important that you provide an opportunity for the airing of last-
minute issues by asking: Is there anything we did not cover today
that you would like me to know about? Are there any questions you
would like to ask me? In this respect, a question that I particularly

199
PRACTICE

favour is this: If when you get home you realize that you wished you
could have asked me something or told me something, what might
that be? In dealing with what your client raises, it is important that you
respond to it and check that the client is satisfied with your response.

Towards the future

Because it is important that your client leaves with a sense of hope


and commitment about implementing what they have learned, it is
important that you ask them how they feel about leaving the pro-
cess at this point. This gives them a second, albeit different way of
raising any unfinished business as was the case with Eugene (see
below). If your client responds with optimism, then it is important
that you reinforce this. However, you also have another chance to
respond to any lingering doubts and reservations they may have
about putting into practice the learning they have derived from
the process. Here is how I concluded the face-to-face session with
Eugene in this respect.

Windy: Before we finish, how do you feel about implement-


ing what you have learned here when you give group
presentations?
Eugene: Well, basically Im hopeful about it.
Windy: Sounds like you have a reservation about it too?
Eugene: Im not sure how long I have to keep practising before I
get the benefit.
Windy: Yes, I understand your concern and I wish I could give
you some kind of timetable. However, what I will say
is that the more regularly you practise, the quicker you
will derive benefits from that practice and then one day
you will realize that you are no longer anxious, but still
duly concerned about giving group presentations. How
does that sound?
Eugene: Yes, of course I would like to have a timetable, but what
you say makes sense.

200
9: SUMMARIZING

Windy: Good. Any other doubts?


Eugene: No, Im looking forward to getting going.
Windy: Im pleased about that and with your determination, Im
sure that your hopes will be realized. Now, lets plan a
date for our three-month follow-up.
Eugene: OK.

201
AFTER THE FACE-TO-FACE SESSION

29
After the face-to-face session: Reflection,
therecording and the transcript
As you will have gathered, there is a lot to get through in the face-to-
face session. This can usually be accomplished in the 50-minute hour,
although if you run over that time, that is perfectly fine. However, given
the modern pace of life, when the client leaves your office, they may be
bombarded with a number of different things competing for their atten-
tion. This is particularly the case if they turn on their mobile phone and/
or tablet as soon as they leave you. My view is that it is important that
your client gives themself some time to reflect on the session that they
have had with you and particularly on what they have learned and how
they are going to implement what they have learned. You would have
already flagged this issue when making an appointment with your client
(see Chapter 19). It is for this reason that I suggest to clients that they
refrain from re-entering their busy world too quickly and spend about
30 minutes by themselves reflecting on the session, what they have
learned and how they are going to put such learning into practice. My
office is near Regents Park so I suggest that they take a walk in the park
or sit on a park bench and reflect there, although some people like to
have hustle and bustle around them rather than quiet to do their reflect-
ing. Some may wish to reflect in writing and others in thought. One of
my SSI-CBT (WD) clients said they would make a drawing during her
reflection period. How they reflect is not as important as that they do so.

The recording and transcript in SSI-CBT (WD):


aidstoreflection

One of the features of my approach to SSI-CBT [which I have


referred to throughout this book as SSI-CBT (WD)] is that I will,

203
PRACTICE

with the clients permission, make a digital recording of the ses-


sion, which I will send them soon after the session finishes and then
I will have the session transcribed by a professional transcriber and,
once received, I will send the client the transcript. These both aid
the clients reflection process after the session and serve to remind
the client of what they have learned. Sometimes, they enable the
client to focus on aspects of the process that seemed more important
on review than they did at the time and, in particular, both contain
accurate references to the summary that either you made or the cli-
ent provided themself. Some clients have said at follow-up that the
transcript, in particular, gave them an opportunity to copy the sum-
mary verbatim which they carried around with them for later review.
Given the vagaries of the human memory, both the recording and
the transcript provide an accurate reminder of what was covered in
the face-to face session and are valuable in this respect. Different
clients value these media differently. Some value both, while others
value one over the other, partly dependent on their learning style.
Clients who find the written word value the transcript while others
who learn better by listening will listen to the recording on an mp3
player, smartphone or tablet. Clients who dont like listening to the
sound of their own voice definitely prefer the transcript. It is for these
reasons that I provide them with both the recording and the transcript
which are included in the price of the SSI-CBT (WD) package.
Occasionally a client does not want me to record the session and I
do, of course, respect this wish and deduct the price of the transcript
(which, of course, is not provided in this case) from the overall cost.
While it is not a part of the process, occasionally a client may wish
to comment on some aspect of the recording and/or transcript. I will
acknowledge this and respond, if necessary, but I will not engage in
ongoing dialogue. If necessary, I will explain this and tell the client
that I look forward to speaking with them at the follow-up session
which needs to be organized at the end of the face-to-face session.

204
THE FOLLOW-UP SESSION AND EVALUATION

30
The follow-up session and evaluation

The follow-up session is the fourth and final point of contact of the
SSI-CBT process. I usually organize this session three months after
the face-to-face session, but you are free to choose the interval that
better suits you, your clientele and the service in which you work, if
appropriate.

Follow-up: for, against or client choice

Not everybody in the single-session therapy community is in


favour of carrying out a follow-up session. Given this, let me begin
by presenting the arguments for and against follow-up as well as
presenting a third option which involves giving the client a choice
on the matter.

Arguments in favour of follow-up

First, let me present the arguments in favour of carrying out follow-


up sessions.

1. Follow-up provides an opportunity for your client to give


feedback on what they have done in the time between the
face-to-face session and the follow-up session. Some argue
that your client is more likely to do the work that they need
to do to achieve their goal if they are expected to provide
such feedback.

205
PRACTICE

2. Knowing that there is a feedback session scheduled offers your


client a sense of care and connection with you as therapist.
3. As your clients welfare is more important than keeping to the
SSI-CBT format, a follow-up session provides the client with an
opportunity to request more help if needed.
4. Follow-up enables you and any service in which you work to carry
out outcome evaluation (i.e. how the client has done). If you do
this, then you will have to give some thought to how you are going
to measure outcome and what forms, if any, you are going to use.
If you are in a service that depends on funding then this may
influence your views on this point since, increasingly,
funding will only be given to new enterprises if the collection
of outcome data is built into the enterprise. In addition, once
a new enterprise has been established, continued funding will
only be forthcoming if SSI-CBT can be shown to be effective
in that treatment setting.
5. Follow-up provides service evaluation data (what the client
thought of the help provided) and such data will help your orga-
nization to improve the service offered.

Arguments against follow-up

Now, let me present the arguments against carrying out follow-up


sessions.

1. Single-session therapy is what it is a single session. Providing


a follow-up session isnt single-session therapy. After all, the
argument goes, in walk-in services, follow-up is not a part of
what is on offer.
2. As noted above, follow-up creates in the clients mind an ongo-
ing connection with the therapist. Rather than this being a
positive feature, it actually serves to dilute the this is it impact
of the single session.

206
THE FOLLOW-UP SESSION AND EVALUATION

3. Not having an opportunity to have contact with the therapist at


follow-up gives your client complete control. It is like a trapeze
artist working without a net.

Client choice

A third approach involves giving the client a choice concerning


whether or not to be involved in follow-up.

Formal follow-up vs informal check-in

If you do decide to incorporate follow-up into your SSI-CBT


approach, you need to decide whether to carry out a formal follow-up
or an informal check-in. Formal follow-up entails a formal evalua-
tion of outcome and of the service. It should be agreed at the end of
the session and an agreed date put in the diary. Informal check-in is
a looser, more general update on the clients progress.

Follow-up in SSI-CBT (WD)

Let me provide my own approach to follow-up.1 At the end of


the face-to-face session, I make a definite appointment to have
a follow-up phone call which lasts between 20 and 30 minutes.
My practice is to schedule the session three months after the
face-to-face session to enable any changes the client has made to
mature and be incorporated into their life. Again, as with the pre-
session phone contact (see Chapter 19), I stress to the client the
importance of them choosing a time where they can talk without
interruption and where they can give their full attention to the
phone call.
I have developed a protocol for the follow-up phone session
which can be found in Box 30.1. Hopefully this is self-explanatory.

207
PRACTICE

Box 30.1 Follow-up telephone evaluation protocol


1. Check that the client has the time to talk now (i. e. approx-
imately 2030 minutes)? Are they able and willing to talk
freely, privately and in confidence?
2. Read to the client their original statement of the problem,
issue, obstacle or complaint. Ask: Do you recall that?
Is that accurate?
3. Using a 5-point scale how would you rate how things are
now with respect to the issue?
(1) ______ (2) ______ (3) _____ (4) ______ (5)
Much worse About the same Much improved
4. What do you think made the change (for better or worse)
possible. If conditions are the same, ask What makes it
stay the same?
5. If people around you give you the feedback that you have
changed, how do they think you have changed?
6. Besides the specific issue of . . . (state the problem), have
there been other areas that have changed (for better or
worse). If so what?
7. Now please let me ask you a few questions about the
therapy that you received. What do you recall from that
session?
8. What do you recall that was particularly helpful or
unhelpful?
9. How have you been able to make use of the session record-
ing and/or transcript if at all? If so, how?
10. Using a 5-point scale, how satisfied are you with the ther-
apy that you received?
(1) ______ (2) ______ (3) ______ (4) ______ (5)
Very dissatisfied Moderately satisfied Extremely satisfied

208
THE FOLLOW-UP SESSION AND EVALUATION

11. Did you find the single-session therapy package to be suf-


ficient? If not, would you wish to resume therapy? Would
you wish to change therapists?
12. If you had any recommendations for improvement in the
service that you received, what would they be?
13. Is there anything else I have not specifically asked you
that you would like me to know?

Thank the client for their time and participation. Remind them
that they can contact you again if they require additional services.

Follow-up: Eugene

In Box 30.2, I provide my notes on my follow-up session with Eugene.


Normally such notes will be in note form in my own handwriting, but
for the purpose of publication I present them in full sentences.

Box 30.2 Follow-up telephone evaluation with Eugene


1. Check that the client has the time to talk now (i.e. approxi-
mately 2030 minutes)? Are they able and willing to talk
freely, privately and in confidence?
Eugene confirmed that he had the time to talk and could
talk freely
2. Read to the client their original statement of the problem,
issue, obstacle or complaint. Ask: Do you recall that? Is
that accurate?
I reviewed with Eugene that he came for help with anxiety
about giving group presentations

209
PRACTICE

3. Using a 5-point scale how would you rate how things are
now with respect to the issue?
(1) ______ (2) ______ (3) _____ (4) ______ (5)
Much worse About the same Much improved
Eugene provided a score of 5
4. What do you think made the change (for better or worse)
possible. If conditions are the same, ask What makes it
stay the same?
Eugene said that he was able to put into practice what he
learned in the SSI-CBT process and gave weekly group
presentations instead of avoiding them
5. If people around you give you the feedback that you have
changed, how do they think you have changed?
Eugene mentioned that his colleagues have remarked that
he seems much more relaxed at work than he used to
and more specifically that his group presentations are
more informal and more humorous, qualities that his
colleagues said they valued
6. Besides the specific issue of anxiety about giving group
presentations, have there been other areas that have
changed (for better or worse). If so, what?
Eugene said that he feels more relaxed at work and has
more time for his friends than he used to. He attributed
both of these things to dealing effectively with his
group presentation anxiety problem
7. Now please let me ask you a few questions about the
therapy that you received. What do you recall from that
session?

210
THE FOLLOW-UP SESSION AND EVALUATION

Eugene recalled quite a lot since he made full use of the


recording and the transcript, particularly the latter.
He said what he remembered most was developing the
short, memorable version of his healthy belief
8. What do you recall that was particularly helpful or unhelpful?
Eugene said that what was most helpful was using the short
memorable version of his healthy belief before every
group presentation. The least helpful aspect was not
being able to have contact with me for three months after
the face-to-face session. Eugene said that he wanted to
share his successes with me, but felt that he couldnt
9. How have you been able to make use of the session record-
ing and/or transcript if at all? If so, how?
Eugene said that he made much use of both the recording
and the transcript, particularly the latter. He had
highlighted bits of the session that he found particularly
helpful and referred to it whenever he thought he
needed to. He did say that as he made progress he
made less use of both the recording and the transcript
10. Using a 5-point scale, how satisfied are you with the ther-
apy that you received?
(1) ______ (2) ______ (3) ______ (4) ______ (5)
Very dissatisfied Moderately satisfied Extremely satisfied

Eugene provided a score of 5


11. Did you find the single-session therapy package to be suf-
ficient? If not, would you wish to resume therapy? Would
you wish to change therapists?
Eugene said that the SSI-CBT package was sufficient

211
PRACTICE

12. If you had any recommendations for improvement in the


service that you received, what would they be?
Eugene suggested that access to the therapist be allowed
between the face-to-face session and the follow-up
session, although he also added that he understood
why such access is not part of the process
13. Is there anything else I have not specifically asked you
that you would like me to know?
Eugene remarked that it would be useful to have this
service provided on the National Health Service as it
was quite expensive. However, he did add that it was a
valuable experience

Thank the client for their time and participation. Remind


them that they can contact you again if they require additional
services.

This brings us to the end of the book. I hope you have enjoyed
reading it and that you may be inspired to develop your own SSI-
CBT practice. If so, and you wish to tell me of your experiences,
please email me on my website, www.windydryden.com.

Note

1 It should be borne in mind that my SSI-CBT (WD) practice is one that is


conducted in an independent practice setting. I have no pressure on me to
provide anyone formal outcome data.

212
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216
Appendix 1

Some technical details relating to the


recording and the transcript
In this appendix, I provide some technical details relating to the
recording and the transcript if you choose to incorporate the use of
one or both into your SSI-CBT approach.

The recording: technical details

You will need a good digital voice recorder to record the face-to-face
session. I have experimented with several different machines and,
in my view, I get the best recordings from the Sony Memory Card
Recorder ICD-LX30. This reasonably priced, small portable stereo
recorder is powered by two AAA batteries although I recommend
getting a Sony 3V mains adapter so that you dont have to worry
about running out of power halfway through a face-to-face session.
The recording is an MP3 and is made onto a Micro SD memory card
which you can upload onto a desktop computer.
You can send the recording via a file-sharing website. I use pCloud
which is very reliable, in my experience. Your client will get an email
from the file-sharing website with a download link so that they can
download the recording onto their computer, tablet or other device.
Normally, the link will only be available for a short period of time
so you should alert your client to look for the email containing
the download link and advise them to download it as soon as it is
received. If you are concerned about security you should investigate
ways in which the file can be encrypted.
There is a way of giving the client a copy of the recording. This
will obviate the necessity of encryption and encourage the client

217
APPENDIX 1

to begin the reflection process without the need to use download


links. There may be other ways of doing this, but this is how I
do it.

You will need to purchase a StarTech USB 2.0 1-to-2 Standalone


Flash Drive Duplicator. This is available from www.startech.
com. At the time of writing (Feb 2016) it costs 112. It comes
with a mains adapter and full, easy-to-understand instructions
for use.
You will need to purchase at least one 256 MB Micro SD card
and a USB Multi Media Memory Card Reader Adapter. The lat-
ter is widely available, but I got mine from StarTech at the same
time as ordering the duplicator and it works very well. You need
to use this size of card so replace the card that is in the Sony
Memory Card Recorder ICD-LX30 (if you are using that) with
the 256 MB card.1
You will need to purchase a number of 256 MB USB flash
drives.
After you have made the recording of the face-to-face session
using the memory card recorder with the 256 MB memory
card that you have purchased and inserted instead of the
Micro SD card that came with your recorder (as above),
remove the card from the recorder and insert it into the USB
card reader adapter. This is now a USB device and can be
inserted into the appropriate slot on the duplicator where
the recording will be copied from (see instruction booklet).
Insert the 256 MB USB Flash Drive into the appropriate slot
on the duplicator where the recording will be copied to (see
instruction booklet). Press the transfer button (see instruc-
tion booklet) and the recording will in a matter of seconds be
copied onto the Flash Drive which can now be given to the
client.
Be sure to erase the recording from the 256 MB memory card so
that it is blank and ready for future use.

218
APPENDIX 1

The transcript: technical details

While it is possible for you to transcribe the recording yourself, this


is probably not an efficient use of your time and you may wish to use
a professional transcriber as I do. There are two types of transcrip-
tion possible; one which includes every um and ah and suchlike
or one that provides a comprehensible, accurate representation of
the session. I use the latter type as it is one that is fit for the present
purpose. At the present time of writing the cost of transcription that I
get charged is 1 per minute of session time. Thus, if the session lasts
50 minutes, I get charged 50 by my transcriber.2 This cost is incor-
porated into the cost of the SSI-CBT (WD) package that I offer. As
I said earlier, if the client does not want the transcription, the price
that it would have cost me gets deducted from the cost to the client.
If the transcriber cannot decipher any words, they flag that up on the
transcription and also in an accompanying email. I will then listen
myself and fill in any blanks that I can. Once received and checked,
I then send the transcript to the client by email attachment. You may
wish to send an encrypted version with instructions concerning how
to unencrypt it.

Notes

1 The duplicator will copy whatever is on the device the recording is on


to the device receiving the copy. This is why I use a 256 MB Micro SD
card as it is large enough to take a recording of a face-to-face session and
cheap. It will record everything on the card which is why you only want
to use it for the recording of a single session and place it on the 256 USB
flash drive. If you use the latter with a Micro SD card that is larger than
256 MB, then it wont copy. You can use a larger size USB flash drive, but
you will be wasting space and expenditure.
2 It is important, of course, to explain the confidential nature of your work
to the transcriber, who also needs to have a confidentiality policy.

219
Index

A (adversity or negative events) acceptance and mindfulness-based


29, 64, 68, 70, 71, 130, 14765, therapy 79, 80, 168
167, 168, 171, 178, 181; helping ACT see Acceptance and
client construct healthy responses Commitment Therapy
to 1568; identifying: magic active-directive style 18, 106
question technique 1501; active engagement in process 90
inferential 150, 1556; setting acute not chronic nominated target
goal in response to inferential problem 56
rather than situational A additional sessions, views on
1556; situational 150, 1556; availability of 20
understanding 14951 adjusting to life, people who find it
ABC cognitive-behavioural model difficult 489
29, 645, 69, 128, 130, 132, 147, adversity (A): client keeps
149, 152, 156, 163, 167, 168; responding unhealthily to, even
assessment of B in 701; and when they correct their distorted
central mechanism 77; Eugenes inferences 345; discussed
ABC assessment for his target in SSI-CBT 2932; healthy
problem and goal 171 negative responses to, based
AC-based goal focus 68 on flexible/non-extreme beliefs
AC-based problem focus 645 about 334; helping clients
Acceptance and Commitment to deal healthily with 2936;
Therapy (ACT) 33, 49, 70, people disturb themselves about,
71, 82 by rigid/extreme beliefs 24;

221
INDEX

response to their response to, assessment 68, 107; ABC 77, 147,
as clients main adversity 34; 171; of B in ABC framework
unhealthy negative responses 701, 147, 169; carry out 6972;
to, based on rigid and extreme and case formulation 6972;
beliefs about 334; when client cognitive 172; of goals 97, 11819;
is stuck in face of 33; when client of problem 63, 97, 11819
reacts to with disturbed feelings associative learning 23
and/or unconstructive behaviour Australia 1
334 authentic chameleon, therapist as
Albert Ellis Institute, New York 4 18, 989
alcohol usage 44, 72, 129, 149, availability of additional sessions,
151, 1635, 171 views on 20
alliance: with therapist 56, 62, 107; avoidance 153, 171; behaviours
see also working alliance theory 149; vs confronting issues 25;
ambivalence 62, 148 strategies 72
anger 35, 45, 49, 148; another aware of emotions, facility in
posing threat to self-esteem being 56
32; being obstructed towards
goal 32; breaking one of own B (belief(s) or thinking) 29, 64,
personal rules (self-anger) 65, 77, 147, 149, 157, 165, 167,
32; disrespect by another 32; 191, 192, 194; assessment of
frustration 32; someone breaking 701; intermediate 70
one of personal rules 32; unjust Barkham, M. 43
treatment 32 Barrett, M. S. 42
anxiety 3, 30, 45, 122, 129, 133, Batten, S. V. 33
1412, 148, 1503, 161, 163, Beck, Aaron T. 4, 29, 70
171, 1789; vs depression 31; behaviour 3, 18, 33, 35, 43,
over exams 734, 78; over group 44, 66, 74, 80, 91, 98, 114;
presentations 145, 165, 169, 170, avoidance 149; constructive
177, 209, 210; public-speaking 158; over-compensatory 149;
34, 48, 128, 187, 188; related reassurance-seeking 149;
adversities in discomfort realm safety-seeking 149; and second
30; related adversities in ego wave CBT 23; self-defeating
realm 30; social 25 82, 83; SSI-CBT and 12;
aphorisms 93, 94, 101 towards others in SSI-CBT
Armstrong, C. 35 (WD) 26; unconstructive 158;
articulation of target problem by unhealthy 157; value-based,
client, clear 91 goal-oriented 24
assertiveness 94, 95; lack of 139 behavioural responses at C 1489

222
INDEX

belief(s) (B or thinking) 29, 64, centrality 141


65, 77, 147, 149, 157, 165, 167, central mechanism behind
191, 192, 194; that therapy is problems: dealing with 1739;
likely to be helpful 56 helping client identify/deal with
Big ILittle i technique 1856 728; identifying 16772; in
blank, mind going 734 SSI-CBT (WD) 748
Bohart, A. C. 41, 42 centre of interest or activity 141
bonds in clienttherapist working chairwork 12, 94, 119
alliance 1718; core conditions change: accepting personal
1718; therapeutic style 18 responsibility for 56; cognitive
borderline personality disorder 48 23; committed reason to
Bordin, E. S. 17 389; discomfort as cost of
breaking personal rules: by self, 39; expecting 16; knowledge
causing self-anger 32; by as ingredient for 38; prepared
someone else, causing anger 32 to accept the costs of 3940;
brief interventions 1, 6, quantum 40
Buckingham, M. 86 characteristics of client, helpful for
building on whats there 15 SSI-CBT 8995
Burry, P. J. 7 checklist: of inclusion/ exclusion
criteria for SSI-CBT 57, 62;
Cde Baca, J. 40, 91, 92 Safrans guidelines for suitability
C (emotional/behavioural for short-term CBT 56; of topics
response to adversity) 29, 64, 70, for pre-session phone call 125
14751, 1557, 159, 1636, 167, Christmas Carol, A (Dickens) 92
168; understanding responses at clarity 91, 141
1489 classical conditioning 23
Cahill, J. 42 clear visual definition 141
Canada 1 client(s): characteristics helpful
cancelling appointments 5, 123 for SSI-CBT 8995; in ongoing
capitalize on successful attempts to therapy who want brief help
solve problem 110 with problem 545; only in
Capra, Frank 92 town for short period who
Capturing the Moment (Hoyt and need some help in that town 55;
Talmon) 1 reflection 112, 119; satisfaction
Carey, T. A. 43 with non-clinically significant
case formulation in SSI-CBT 69, improvement 42; strengths,
712, 97 helping identify 856; suitable
CBT see Cognitive Behavioural for short-term CBT may also be
Therapy suitable for SSI-CBT; in therapy

223
INDEX

seeking second opinion (or their short-term, people suitable for,


therapists are) 534; variables, may also be suitable for SSI-
draw up range of in SSI-CBT CBT 567; talking therapy 184;
858; welfare 11; who volunteer third wave therapists 234; as
for demonstration session before tradition rather than approach
audience 55 12, 17, 23, 142; videotaped
Clifton, D. 86 demonstration session 556
clinically significant vs cognitive change 23, 182
non-clinically significant cognitive distortions 167
improvement 42 cognitive processes, modifying
clinical problems, people with 50 dysfunctional 80
close relationships with clients, cognitive responses at C 149
therapist does not need 98 cognitive therapy 4, 29, 41
coaching 501, 122 Cognitive Therapy and the
cognitions 13, 701, 83, 149, 167, Emotional Disorders (Beck) 29
191, 193; problematic 7982, committed reason to change 389
109, 110, 119, 147, 163, 165, compassionate acceptance 24
16879, 195 compliance 90
cognitive behavioural factors components of SSI-CBT 19; face-
behind peoples problems 237 to-face session 19; follow-up
Cognitive Behavioural session 19; initial point of
Modification 4 contact 11, 19; pre-session phone
Cognitive Behavioural Therapy 11, 19
(CBT) 4, 5, 6, 11, 45, 49, 50, conditioning, classical 23
81, 191, 195; ABC framework confidentiality 19, 123, 219
147; active-directive therapeutic confronting vs avoiding issues 25
style 106; Beckian 70; different connecting with / trusting therapist
approaches to 99, 162, 167, quickly, difficulty 59
170; four-stage strengths-based contact: face-to-face session
model to promote resilience 85; 19; first 11, 11718, 1214;
goal-oriented 108; modification- follow-up session 19; initial
based 7980; ongoing 70, 71, point of 11, 19; pre-session see
93, 114, 121, 122, 123, 143, pre-session telephone contact;
1934; people seeking advice telephone see telephone contact
on how CBT would tackle their contraindications for SSI-CBT
own problem 52; second wave 5962; difficult to connect
therapists 23; short-term, people with/trust therapist quickly 59;
not suitable for, are generally difficulty accessing thinking
not suitable for SSI-CBT 612; processes 62; difficulty being

224
INDEX

aware of emotions 62; difficulty 1749; first contact 122; focus


developing alliance with therapist on goals 668; generalizing from
62; does not agree there is goal: Eugene 165; generalizing
relationship between thinking from target problem: Eugene
and feeling 62; does not take 1523; identifying central
personal responsibility for change mechanism in SSI-CBT (WD):
62; people needing ongoing Eugene 16971; setting goal
therapy 60; people not suitable with respect to target problem:
for short-term CBT are generally Eugene 1613; towards
not suitable for SSI-CBT 612; the future: Eugene 2001;
people requesting ongoing understanding target problem:
therapy 59; people who are likely Eugene 1523
to feel abandoned by therapist 61; Dickens, Charles 92
people who dont want CBT of differential effectiveness among
any description 60; people who therapists 120
have vague complaints and cant digital voice recording (DVR) 5, 7,
be specific 601 112, 119, 123, 204
Cooper 12 disapproval 30
core conditions 1718 disclosure of negative information
core values 127 about self 30
couples therapy 122 discomfort 30, 75, 130, 145, 182,
Cowley, J. 48 194; experiencing, as cost
crisis management, people who of change 39; intolerance vs
require prompt and focused 50 discomfort tolerance 267;
criticism 30 intolerance belief 26, 75, 76;
realm (persons sense of comfort)
Davis III, T. E. 3, 39, 50 29; tolerance belief 75, 76
demonstration session, people who Disraeli, Benjamin 39
volunteer for before audience 55 disrespect from another causing
depression 301, 41, 45, 80, 81, 94, anger 32
148; vs anxiety 31 distorted inferences: client keeps
de Shazer, S. 214 responding unhealthily to
dialogues, clienttherapist: adversity even when they correct
AC-based problem focus 645; 345
beginning face-to-face session: distress intolerance 26
Eugene 140; creating focus disturbed responses, positive
1412; creating focus: Eugene reinforcement of 23
145; dealing with central doubt(s): about existence of
mechanism in SSI-CBT (WD) purity related to core aspect of

225
INDEX

personal domain 30; identifying engage client quickly 105


and responding to 11314; envy 32, 45, 148
reservations or objections Epictetus 23, 167
(DROs) 114; those that may be ET see early termination
expressed non-verbally 114 exam anxiety 734
drop-in centres 2 expect change 16
drop-in services 7 explain what you plan to do in
dropout from therapy 2; definition SSI-CBT 109
2; and privileging your clients extreme beliefs and rigid beliefs
viewpoints in SSI-CBT 413 33, 46, 70, 71, 173, 1779; about
DROs see doubts, reservations or adversity 34; vs flexible and non-
objections extreme beliefs 245
Dryden, W. 17, 24, 29, 45, 148, 150
drugs, use of 3, 149 face-to-face session 11, 11819; 1.
DSM-V 45 beginning 13740; 2. creating a
Duncan, B. L. 12 focus 1415; 3. understanding
DVR see digital voice recording target problem 14754; 4. setting
dysfunctional assumptions and goal 15565; 5. identifying
schemas 23, 167 central mechanism 16772; 6.
dealing with central mechanism
early termination (ET) 42 1739; 7. making an impact 1819;
Eccles, J. S. 108 8. encouraging client to apply
ego realm (persons estimation of learning 1915; 9. summarizing,
themselves) 29; anxiety-related closing and clients commitment
adversities in 30 to future 197201; reflection,
elevator phobia 3740, 89 recording and transcript after
eliminating experience 72 2034
Ellis, Albert 4, 7, 379, 70, 95, 114 failure 7981; anxiety and 30;
email summary of salient points depression and 30; within
from pre-session phone call personal domain 30
1324; matters arising from false start 94, 143
13940 fast engagement with clients,
emotional impact 13, 21, 94, 101; therapist capacity for 98
look for ways of making 114, 119 feeling and thinking, relationship
emotional problems 29, 45, 46, between 56
49, 50 fees, flexibility about charging
emotional responses at C 148 97
empathy in therapistclient first contact 11, 11718, 1214;
encounters 17 with Eugene 1223

226
INDEX

first response see subsequent generalization 74; be mindful of


responses more important than opportunities for 10910; from
first response goal 1645; of learning 63, 712,
first wave therapists 23 93, 101, 110, 119, 164, 178, 194;
Flaxman, P. E. 45 from target problem 154
flexibility of therapist: about genuineness in therapistclient
charging fees 97; and pluralistic encounters 17
outlook 99 Gestalt Therapy 4
flexible and non-extreme beliefs Gloria 3, 7
74; in response to negative Gloria films 34, 5
events 24 goal(s): achievement 18; ask what
focus: on both problems and goals client is prepared to sacrifice
638; creating, in face-to-face to achieve 1089; assessment
session 1415; keeping to, 11819; elicit clients, and
or changing it 143; problem, keep focused on this 108; focus
solution or both 1423; quickly, on 658; generalizing from
therapist can help client 100; 1645; what person may lose by
what is it? 1412 achieving 72; of working alliance
focused: being, and helping client 201
stay focused 106; open-ended goal-oriented focus, ensure
questions 90 underpinned by value if possible
follow-up session 11, 11920; 108
arguments against 2067; goal-setting 143, 15565;
arguments in favour of 2056; negotiating responses to
client choice 207; and evaluation effective, in SSI-CBT 15861;
20512; for, against or client negotiating responses with
choice 205; formal, vs informal respect to target problem:
check-in 207; plan for and carry Eugene 1614; questions for
out 115; in SSI-CBT (WD) 207; 155; in response to inferential
telephone evaluation protocol rather than situational A 1556
2089 good practice in SSI-CBT 10515;
formal style 18 ask what client is prepared to
four-stage strengths-based CBT sacrifice to achieve their goal
model to promote resilience 85 1089; assess problem with
Friday Night Live 7 imminent, future example if
Friday Night Workshops (of Albert possible 1078; be active-
Ellis) 4, 5 directive 106; be clear about
frustration 32 what you both can and cant
future-centred focus 1314 do 1056; be clear about why

227
INDEX

you are both here 1056; be emotional impact 114; make


focused and help client stay liberal use of questions 112; plan
focused 106; be mindful of for and carry out follow-up 115;
opportunities for generalization and seek clients permission to
10910; capitalize on successful proceed 109; summarize or have
attempts to solve problem 110; client summarize session 115
check out clients understanding group presentations: anxiety over
of your substantive points 113; 145, 165, 169, 170, 177, 209,
develop rapport through the 210; giving 133
work 105; distance yourself Groves, V. 48
from unsuccessful attempts guilt 5, 45, 658, 148; types of 31
to solve problem 110; elicit
clients goal and keep focused handheld vs professional juicer
on this 108; encourage client analogy for pre-session checklist
reflect throughout process 1256
11112; encourage client to harming others, guilt over 31
be specific 10910; encourage Harris, R. 193
client to prepare 111; engage Hayes, S. C. 23
client quickly 105; ensure client healthy behaviour responses 157
answers questions you ask them healthy cognitive responses 157
11213; ensure client has plan healthy emotional responses 1578
to implement meaningful point healthy negative responses to
from process 11415; ensure adversity 33; REBT and 75
client takes one meaningful healthy responses to adversity:
point from process 11415; behavioural 157; cognitive 157;
ensure goal-oriented focus is emotional 1578; helping client
underpinned by value if possible construct 1568
108; explain what you plan to healthy vs unhealthy stances
do in SSI-CBT 109; give client towards problems 256
time to answer your questions help across life cycle, people
113; identify and be mindful of who view therapy as providing
clients learning style 11011; intermittent 4950
identify and make use of clients helpful client characteristics for
strengths 110; identify and SSI-CBT 8995; can focus and
respond to clients doubts, articulate target problem and
reservations and objections related goal 91; can move with
11314; identify previous relative ease from specific to
attempts to solve problem general and back again 93; can
110; look for ways of making relate to metaphors, aphorisms,

228
INDEX

stories and imagery 934; has homework assignments 923, 107,


sense of humour 95; open to your 114, 193; report on 1389
ideas as therapist, but able to honesty 130, 186, 198, 199
disagree with you 90; prepared Hoyt, M. F. 1, 2, 42, 57
to be as actively engaged as Hoyt and Talmons case for clinical
possible in process 90; prepared utility of SST 434
to engage in activities where they humour 18, 141; use of 956,
can practise solutions in session 1867
945; prepared to put into hurt 45, 66, 148; types of 312
practice what they learn from hurting feelings of others, guilt
contact with you 923; ready to over 31
take care of business now 8990; hypnosis 130, 133
realistic about what can be
achieved in SSI-CBT 912 imagery 93, 94, 101, 188;
helpful therapist characteristics encouraging client to apply
for SSI-CBT 97102; can be learning using 1915
authentic chameleon 989; can impact, making an 1819; Big
help client focus quickly 100; ILittle i technique 1856;
can move with relative ease consider using self-disclosure
from specific to general and 1878; find/use something that
back again 100; can quickly resonates with / helps client 1812;
engage with clients 98; can think help client develop impactful
quickly on their feet 100; can version of their healthy thinking
tolerate lack of information about 1889; make use of clients
clients 97; can use metaphors, strengths 1823; refer to clients
aphorisms, stories and imagery core values to promote change
and tailor them to client 1012; 186; refer to clients role model
does not need close relationships or someone who has helped 183;
with clients 98; has realistic rigid belief vs flexible belief 184;
expectations of SSI-CBT 1001; structure interventions to reflect
is flexible and has pluralistic clients help in past 182; use
outlook 99 humour judiciously 1867; use
helpful to client: discover which range of techniques but construct
people have been most 86; your own 188; utilize clients
discover which principles client learning style 1834; utilize
has found helpful in life 87; visual medium as well as verbal
focus on memorable occasion of medium 1846
being helped 86; identify what important imminent decision,
was helpful 86 people requiring to make 48

229
INDEX

improvement, clinically significant 203; application by client inside


vs non-clinically significant 42 and outside session 1915;
inferences 13, 35, 149, 150, 162, associative 23; discover how
169; distorted 25, 34, 157 client best learns 88; generalizing
inferential A 150, 1557, 15961, 63, 712, 93, 101, 110, 119, 164,
178 178, 194; preferred way of 127,
informal style 18 131; style, clients 88, 11011,
informed consent to proceed; verbal 1834, 204
125; written form 136 Lemma, A. 186
initial point of contact 11, 19 Lewin, Kurt 77
intensive one-session treatment of life cycle, therapy providing
single phobias (st) 39, 50 intermittent help across 4950
intermediate beliefs 70 life dilemmas and quandaries,
internalization 90 people with 48
interruption 74, 106, 109, 115, 124, loss from personal domain 30
207; prepare client for possible Lukens, E. P. 52
1445; with tact 145
intolerance see discomfort McFarlane, W. R. 52
intolerance vs discomfort McLeod, J. 12
tolerance magic question technique for
irrational beliefs 167 identifying A 1501
Its a Wonderful Life (Capra) 92 maladaptive schemas 167
Maluccio, A. N. 41, 42
Jacobson, L. 16 Martha 48
jealousy 32, 45, 148 Meichenbaum, Donald 4
Joffe, Debbie 4 meta-emotional problems, people
Jones-Smith, E. 85 with 49
metaphors, use of 18, 93, 94, 101,
Kathy films 4, 5 173, 188
Keller, G. 115 meta-problems 26, 148, 154;
Kellogg, S. 12, 94, 192 looking for presence of 151;
Kelly, George 18, 21 should it be target problem? 151
Kennedy, John F. 50 Miller, W. R. 40, 91, 92
knowledge 39, 41, 64, 65, 86, 149; mindfulness 24, 79, 80, 168,
as ingredient for change 38 179, 195
mind going blank 734
Lazarus, Arnold 4, 18, 98 mistrust 62
learning 5, 12, 44, 92, 101, 107, modification-based CBT 4, 80, 83,
112, 113, 148, 189, 197, 200, 168, 179, 191, 193, 194

230
INDEX

Mooney, K. A. 85 relationship issues at home and


motivation 119; lack of 39, 77 work 46
Multimodal Therapy 4 non-extreme and flexible beliefs 25,
33, 46, 75, 174, 177, 183, 188; in
NATs see negative automatic response to negative events 24
thoughts notes for pre-session call,
negative automatic thoughts (NATs) therapists 128, 136
23, 70, 167 notice change task, report on
negative events 29; response to 24; 1378
see also A; adversity
negative feelings of client; obstructed towards goal, being 32
disturbed 334 one meaningful point from process,
negative judgment from others 30 ensure client takes 11415
new meaning for client 13 ongoing therapy 1, 6, 29, 34, 54,
no gains, without pains 39 55, 79, 1223, 151; people
nominated target problem acute not needing 60; people requesting 59
chronic 56 open-ended questions, focused 90
non-awfulizing belief 75 open-mindedness, client 90; and
non-clinical problems 4550; theory-driven therapy, example
people amenable to single- of 748
session approach; people st, L. G. 39; intensive one-session
experiencing everyday problems treatment of single phobias
of self-discipline 467; people 39, 50
requiring to make important over-compensation 72
imminent decision 48; people over-compensatory behaviours 149
who find it difficult adjusting over-responsiveness 26
to life 489; people who need oversensitivity 26
help to get unstuck and move on overview of SSI-CBT process
47; people who require prompt 11720; face-to-face session
and focused crisis management 11819; first contact 11718;
50; people who view therapy follow-up session 11920; pre-
as providing intermittent help session telephone contact 118
across life cycle 4950; people zil, Mesut 113
with clinical problems but ready
to tackle non-clinical problems Padesky, C. A. 85
478; people with life dilemmas panic disorder 3, 50
and quandaries 48; people Papasan, J. 115
with meta-emotional problems parables, use of 18
49; problems of living 456; Pashler, H. 88

231
INDEX

Perl, Fritz 3 privileging your clients viewpoints


personal domain 29; discomfort in SSI-CBT 414; and dropout
realm (persons sense of from therapy 413; and Hoyt and
comfort) 29; ego realm (persons Talmons case for clinical utility
estimation of themselves) of SST 434
29; guilt and moral sphere of problematic cognitions 7982,
31; shame and being judged 109, 119, 147, 165, 167, 173;
negatively for personal weakness identifying in SSI-CBT (WD)
within 31; shame and falling 16872
short of ideas within 31 problematic urges 823
personal responsibility for change, problem(s): AC-based focus
accepting 56 645; advantages in having
Person Centred Therapy 3 72; assessment 118; avoidance
Persons, J. B. 41 of 72; clients reaction to 72;
phobias 3, 50; elevator 3740, 89; focus on 635; involving others
treatment of 39 in 72; over-compensation for
physiological responses at C 148 having 72
plan for and carry out follow-up Problems of Living 7
115 procrastination 5, 767
pluralistic outlook of therapist 99 professional vs handheld juicer
pluralistic therapy 12 analogy for pre-session checklist
positive reinforcement of disturbed 1256
responses 23 psychoeducation 523; for people
practising solutions to problem 119 open to therapy who want to
preferred way of learning, clients try it first before committing
127, 131 themselves 52; for people
preparing and nominating time for reluctant about seeking therapy
face-to-face session 136 and only prepared to commit
present-centred focus 1314 to one session 53; for people
pre-session telephone contact seeking advice on how CBT
11, 19, 92, 112, 118, 12536; would tackle their own problem
protocol questions 127; protocol 52; for therapy trainees who
questions and replies (Eugene) want to experience therapy from
12832; update since phone different perspective 53
session 137; when this proves psychological problems 23, 27, 52
sufficient 1345 psychotherapy 17, 43, 53, 98
prevention 51 public speaking anxiety 34, 48,
principles client has found helpful 128, 187, 188
in life 87 Pygmalian effect 16

232
INDEX

quandaries, people with 48 reflection, client 5, 112, 119, 184,


quantum change 40, 912, 100 218; after face-to-face session
questions: ensure client answers 2034; recording and transcript in
11213; give client time to answer SSI-CBT (WD) as aids to 2034
113; make liberal use of 112 Reinecke, Angela 3, 50
quick engagement with clients, rejection 25, 30
therapist capacity for 98 relationship(s): between thinking
quick self-help, special and feeling, readily agreeing that
circumstances for 3740; there is 56; few and mistrusting
committed reason to change 62; issues at home and work 46;
389; Elliss vignette regarding sustained and trusting 62
378; knowledge as ingredient report: on homework 1389; on
for change 38; prepared to accept notice change task 1378
the costs of change 3940 resilience: four-stage strengths-
based CBT model to promote 85
rapport through the work, respectfulness in therapistclient
develop 105 encounters 17
Rational Emotive Behaviour Richard films 4, 5
Therapy (REBT) 4, 7, 24, 33, 37, rigid beliefs see extreme beliefs and
47, 70, 77, 162, 170; flexible/ rigid beliefs
non-extreme/non-awfulizing Rogers, Carl 3, 7
beliefs 75; helps identify/deal role-models, discover clients
with central mechanism 74; lends 878, 127
itself to SST 74 role-play 94, 119, 145; encouraging
Ratner, H. 216 client to apply learning using
ready to take care of business now 1912
8990 Rosenthal, R. 16
realistic expectations of SSI-CBT, rudeness 145
therapist needs to have 1001
reassurance-seeking behaviours 3, safety-seeking behaviours 3,
72, 149 72, 149
REBT see Rational Emotive Safran, J. D. 567, 61, 62
Behaviour Therapy Safrans guidelines for suitability
recording 5, 7, 211; session 119, for short-term CBT 56
208; technical details relating to Salkovskis, P. M. 3
21719; and transcript in SSI- schemas 13; core 70; dysfunctional
CBT (WD) as aids to reflection 23, 167
2034; see also digital voice second wave CBT therapists 23
recording self-control, lack of 30

233
INDEX

self-defeating behaviour 82, 83 to effective goal-setting in


self-discipline 467 15861; not one-shot deal 1415;
self-disclosure 109, 1878 overview of process 11720;
self-esteem 32 and peoples capability for quick
self-revelation and shame 31 self-help 378; power is in client
self-rushing 133 16; present- and future-centred
SFT see solution-focused therapy foci 1314; and prevention
shame 31, 34, 45, 49, 80, 81, 148, 51; realistic about what can be
151, 179, 187 achieved in 912; starts before
shameful revelation 31 first contact, continues long after
shyness 129 final contact 14; take away one
single face-to-face session see face- thing from session 1516; this
to-face session is it 13; views on components of
single session: case for clinical 19; what is it? 1113; who can
utility of 434; people amenable benefit from? 4557; working
to 47 alliance theory as generic
Single-Session Integrated framework 1721; you do not
Cognitive Behaviour Therapy have to rush 15
(SSI-CBT) 5, 6; assessment Single-Session Integrated Cognitive
and case formulaton in 6972; Behaviour Therapy: Dryden
basic assumptions 1316; and Approach (SSI-CBT (WD))
behaviour 12; build on whats 11, 12, 13, 70, 73, 74, 77, 99,
there 15; and coaching 501; 119, 148, 150, 160, 162, 173,
contraindications for 5962; draw 184, 188, 2034, 207, 212;
up range of client variables in avoiding vs confronting issues
858; expect change 16; focus on 25; behaviour towards others 26;
both problems and goals 638; clients reactions to adversity
good practice in 10515; helpful 334; discomfort intolerance
client characteristics for 8995; vs discomfort tolerance 267;
helpful therapist characteristics follow-up in 207; identifying
for 97102; helping client problematic cognitions in 16872;
identify/deal with central in recording and transcript as
mechanism behind problems aids to reflection 2034; rigid/
728; helping client identify extreme beliefs vs flexible/non-
strengths they can draw upon to extreme beliefs 245; unhealthy
get most out of 856; importance vs healthy stances towards
of privileging your clients problems 256; when should you
viewpoints in 414; its all help clients deal with adversities
here 13; negotiating responses in 336

234
INDEX

Single-Session Therapy (SST) 5, and problematic urges 823;


6, 434, 117; authors personal when unable to avoid situation in
journey 36; definitions, which person experiences urge 82
Drydens 12; definitions, substantive points, check out clients
Talmons 12; recent history 13 understanding of your 113
situational A 150, 155, 156, summarize session 115, 119,
15961 197201; dealing with loose
social sitations, fear in 73 ends 199200; towards the future
solution-focused therapy (SFT) 2001
12, 142 you, as therapist, provide summary
specific target problem: ability to 1978; your client provides
focus on 56; client can move at summary 199
ease from specific to general and
back again 93; encourage client Talmon, Moshe 1, 2, 5, 12, 20, 42,
to be specific 10910; inability to 434, 57
focus on 62; therapist can move target problems 634; clients
at ease from specific to general reaction to 72; generalizing
and back again 101 from 154; identifying 118;
spiritual epiphanies 40 should meta-problem be 151;
SSI-CBT see Single-Session understanding: Eugene 1523
Integrated Cognitive Behaviour tasks of working alliance 21
Therapy taster sessions 6
SSI-CBT (WD) see Single-Session telephone contact: follow-up
Integrated Cognitive Behaviour evaluation protocol 2089;
Therapy: Dryden Approach pre-session see pre-session
SST see Single-Session Therapy telephone contact
stories, use of 18, 93, 94, 101, 188 theory-driven therapy and open-
strengths-based approaches 12; mindedness, example of 748
client strengths 856, 127; four- therapeutic orientation 3
stage CBT model to pro-mote therapeutic style 18, 106
resilience 85 therapist(s): as authentic chameleon
stuck, people who are 33, 47, 91, 18; first wave 23; helpful
100, 106, 122, 155, 158 characteristics for SSI-CBT
subsequent responses: to adversity 97102; second wave 23; third
(table) 81; more important than wave 234
first response 7983; to persons therapy trainees 53
first response to an adversity, thinking: difficulty accessing
two approaches to 83; and thinking processes 62; errors
problematic cognitions 7982; 23; and feeling, relationship

235
INDEX

between 56; healthy 1889; vague complaints, people who have


processes, facility in accessing 601
56; quickly on their feet, vague goal 159
therapist need facility for 100; value-based, goal-oriented
see also B; belief(s); behaviour 24
third wave CBT therapists 234 value-based living 79
threat(s) 30, 32, 64, 65, 74, 148, 182 verbal informed consent to
time for face-to-face session, proceed 125
preparing and nominating 136 very brief intervention 6
tolerance: for lack of information videotaped demonstration session
about clients 97; see also of CBT 556
discomfort intolerance vs views in clienttherapist working
discomfort tolerance alliance 1920; on availability
transcript: in SSI-CBT (WD) as aid of additional sessions 20;
to reflection 2034; technical on cognitive-behavioural
details 219 conceptualization 20; on
transformational chairwork 12 components of SSI-CBT 19
treatment length 43
troublesome cognitions 7982, Wade, A. G. 41, 42
109, 110, 119, 147, 163, 165, walk-in clinics 1
16879, 195 Wegner, D. M. 81
troublesome issues: avoids discussing Weir, S. 43
62; willing to discuss 56 Wessler, Richard 35
two-chair dialogue 192 Westmacott, R. 42
who can benefit from SSI-CBT?
uncertainty concerning ones physical 4557; clinical problems
and/or mental well-being 30 50; non-clinical problems
unconstructive behaviour 334 4550; other contexts 53;
undeserved plight experienced by psychoeducation 523
self or others 30 Wigfield, A. 108
unhealthy negative emotions about working alliance theory 16, 71, 78,
adversity: caused by rigid/ 98, 113, 143; bonds 1718; as
extreme beliefs 75; vs healthy generic framework for SSI-CBT
stances towards problems 256 1721; goals 201; tasks 21;
unjust treatment causing anger 32 views 1920
update since phone session 137
urges, problematic 823 Zvolensky, M. J. 27

236