Amid an ongoing national mental health crisis (“Stress in America 2020 Survey Signals a Growing National Mental Health Crisis,” APA, 2020), the work of psychologists is more important than ever. But for the growing number of people who need mental health support, seeing a psychotherapist isn’t always a possibility. A shortage of clinicians and a surge in demand has resulted in months-long patient waiting lists. Logistical factors like cost, location, busy schedules, and even cultural stigmas about mental illness may also stand between therapists and potential patients.
Psychologists have identified a potential way to overcome barriers to accessing mental health treatment in a growing body of research on single-session interventions (SSIs). When time is of the essence—for example, addressing a challenge before a big transition or when multiple sessions of therapy aren’t readily available or accessible—psychologists have curated single therapy sessions or other psychology-based interventions to facilitate fast, and sometimes lasting, growth in patients.
Psychological research has long shown that it’s possible to facilitate sudden gains—or fast growth—through therapy. SSIs build on that idea by concentrating evidence-based therapy components and psychological principles within a single session, which may help patients manage everyday stressors and mental conditions like anxiety and depression.
“In the past, we’ve had the idea that growth happens randomly or out of the blue, but single-session intervention work suggests you can curate growth,” said Jessica Schleider, PhD, assistant professor of clinical psychology at Stony Brook University. “We can do things to optimize the likelihood of a client’s gain.”
Here’s what research suggests about how single-session interventions can help, and how therapists are leveraging this knowledge to help improve their patients’ lives.
Defining single-session intervention
All therapists want their patients to get better, and in many situations they prescribe multiple sessions of therapy as the plan toward that goal. But ongoing therapy can be costly and time-consuming—and not every patient wants to attend multiple sessions. Data suggest that even when a therapist recommends ongoing treatment sessions, most patients don’t return after their first meeting with a therapist (Single-Session Therapy by Walk-in or Appointment, Routledge, 2018).
According to Schleider, therapists should provide patients what they need, not what the therapist would prefer as a therapy dosage. SSIs are one way to do that.
Like psychological first aid, single-session interventions give support to people who need it, when they need it. The distinguishing factor is that SSIs don’t assume that people will pursue therapy later; the psychological skills are embedded within one session. Psychologists have identified several strategies that seem to improve people’s symptoms and well-being, from one-time individual and group sessions to digital interventions based on psychological principles.
Psychotherapy usually occurs over a period of time and uses different therapeutic approaches, and the therapist–patient relationship is one component of what helps people grow over time. Typically, ongoing therapy begins with a diagnostic assessment and creation of a treatment plan. With single-session therapy, there is no ongoing treatment plan. Instead, SSIs squeeze the most useful therapeutic strategies into one optimized session that provides the patient with tools they need to help themselves grow, without assuming they’ll come back for more.
SSIs are used in a variety of settings, including mental health clinics, schools and universities, and even primary care clinics and emergency departments. The common denominator in all these modalities: their ability to facilitate growth in a brief period of time.
Overcoming systemic barriers to therapy
One of the most significant barriers to mental health access is a shortage of therapists, and the ongoing COVID-19 pandemic has exacerbated that shortage. People who are motivated to pursue psychotherapy often have to wait months to see a provider, which Schleider said can cause their conditions to worsen or reduce their motivation to seek care.
To prevent these issues in future patients, Schleider’s lab has adapted a solution-focused therapy model that fits into a single session and administers it to people on clinic waitlists. “We wanted to see if we could increase motivation for treatment while folks were waiting and prevent their conditions from worsening by boosting agency and hope in the meantime,” Schleider said.
So far, the intervention shows promise: In a 1-hour session with a trainee, patients identify goals and create an action plan to cope with their mental health condition or stressor. After the session, participants reported significant pre- to post-intervention improvement in perceived agency and hopelessness and rated the session as highly acceptable and useful (The Behavior Therapist, Vol. 44, No. 1, 2021).
For some people, barriers like busy schedules and financial difficulties make it less desirable to pursue therapy, especially among marginalized communities. According to Shalena Heard, PhD, a Maryland-based clinical psychologist, people of color—who are subject to systemic inequities—often don’t pursue mental health services until an emergency occurs. In response to these societal injustices, Heard has found a creative route to improve her patients’ mental health in psychological assessments.
Because Heard often works with marginalized populations who aren’t likely to access care as a result of financial barriers or cultural stigmas about therapy, she incorporates psychological skill-building into her initial assessment. “If this is the only time the person will be working with a mental health professional, I want them to get as many strategies as possible,” Heard said. Along with introducing coping skills for anxiety, depression, and attention-deficit/hyperactivity disorder, Heard shares mental health-supporting resources her patients may be more likely to pursue than therapy, such as school- and community-based mentorship, group therapy, and even psychoeducation-focused apps and podcasts.
Digital SSIs are another option, especially when stigma about traditional therapy is involved. John R. Weisz, PhD, professor of psychology at Harvard University, has collaborated with an international team in developing an intervention for adolescents in Kenya, where he said people often don’t seek mental health care because of stigma and a shortage of professional providers. Using positive psychology principles like gratitude, growth mindset, and value affirmation, the team created a four-session, in-person group intervention—Shamiri (which means “thrive” in Swahili)—led by trained high school students, then distilled the program into a computer-guided SSI called Shamiri-Digital. The in-person version of Shamiri has reduced both depression and anxiety significantly (JAMA Psychiatryopens in new window, Vol. 78, No. 8, 2021), and Shamiri-Digital, administered in students’ computer classes, has significantly reduced depression (Journal of Consulting and Clinical Psychologyopens in new window, Vol. 88, No. 7, 2020).
Unlike other apps and other online resources available today, Shamiri-Digital does not require repeated engagement with digital content or a provider seen remotely. Instead, it is a self-contained intervention that’s completed in a single sitting, in just 1 hour. Shamiri-Digital can provide mental health support that is much more accessible than traditional psychotherapy, particularly in regions where there are relatively few professional providers. It is also more economical for those who can’t afford mental health services, costing less than $4 per student to access rather than hundreds of dollars in traditional therapy (Journal of Consulting and Clinical Psychologyopens in new window, Vol. 89, No. 8, 2021).
Providing growth tools without a commitment
Some SSIs are designed to provide basic coping tools when someone doesn’t need or want ongoing psychotherapy. “For example, for some people with conditions like anxiety, depression, insomnia, or chronic pain, long-term therapy may not be necessary for improvement,” said Lorenzo Lorenzo-Luaces, PhD, assistant professor of psychological and brain sciences at Indiana University.
Athletes, for example—who often need quick growth results before a game—may benefit from SSIs. Tyler Bradstreet, PhD, associate athletics director for psychological health and performance at Texas Tech University, frequently uses single sessions to support athletes on an as-needed basis to address specific issues, like sports-related concerns or relationship issues. “Not every athlete is going to want or need traditional therapy, but every athlete could benefit from psychological intervention, because they have to be in top physical and mental shape to perform at a high level,” Bradstreet said. Stress that significantly affects their performance for even a single game could derail a career, so the timeline of traditional therapy often doesn’t work for them. To facilitate faster growth, Bradstreet uses sports principles like endurance, flexibility, balance, and strength to teach psychological skills.
College students, whose schedules may be unpredictable, can also benefit from single sessions. At the University of California, Santa Barbara, the counseling center offers single-session therapy for students using cognitive behavioral therapy (CBT) and mindfulness tools. Turi Honegger, PhD, the school’s clinical director, said the ability to access support quickly is key for people who express interest. “That sort of immediacy capitalizes on the initial desire to do something about the problem,” he said. “It creates a momentum that carries people forward.”
Schleider’s research also reflects the efficacy of SSIs among young people, especially when combined with digital platforms. In 2020, she and her colleagues evaluated a self-guided digital SSI for adolescents. Along with teaching CBT skills for coping with anxiety and depression, the intervention emphasizes empowerment—an ingredient Schleider said is often missing for young people in therapy settings. Even 3 months after the SSI, participants reported a reduction in anxiety, depression symptoms, and hopelessness (Nature Human Behaviouropens in new window, 2021).
Schleider suspects the empowerment component is the most important in facilitating long-term growth. Depression and anxiety symptoms often cause people to feel “stuck,” but learning about the brain’s ability to change, along with learning effective new coping mechanisms, can be empowering. “All of us have a built-in potential for change that includes depression and anxiety symptoms that feel permanent, but biologically they’re not,” Schleider said. “The intervention teaches them why that is and how to take advantage of opportunities to grow.”
Preventing future mental health concerns
Single-session interventions can also be used as a tool to promote general well-being and resilience, which could reduce the need for mental health services later on. David B. Feldman, PhD, professor of counseling psychology at Santa Clara University, developed a “hope workshop” designed to help people increase resilience to stress, building on C. R. Snyder’s research on hope. In his research, Snyder defines hope as “the process of thinking about one’s goals, along with the motivation to move toward and the ways to achieve those goals” (Journal of Counseling & Development, Vol. 73, No. 3, 1995).
In the group intervention, a leader helps participants set goals, strategize how to achieve their goals, and visualize achieving those goals and overcoming potential obstacles. Research suggests that, by the end of the intervention, participants feel more hopeful about their lives and report more meaning in their life purpose (Journal of Happiness Studies, Vol. 13, No. 4, 2012). A month later, participants had made more progress in their goals than those in a control group. Although Feldman doesn’t consider the hope workshop to be psychotherapy, he says the improvement in resilience could cause depression and anxiety symptoms to decrease.
Psychologists seem to agree that a population health approach to single-session interventions could also be a preventative tool. Weisz and colleagues, for instance, are piloting four school-based SSIs in Ontario, Canada, in partnership with School Mental Health Ontario, an organization that supports a large consortium of school districts. In Ontario, the SSIs are used in concert with school counselor support. The counselors help the students choose the most appropriate digital intervention, and after the intervention is completed, the counselors talk with the students about what they learned and how it can be applied to their lives.
Similarly, Akash Wasil, a doctoral student in psychology at the University of Pennsylvania, helped create a 45- to 60-minute digital intervention that uses the CBT and positive psychology techniques most likely to help adolescents and young adults with anxiety and depression symptoms. His Common Elements Toolbox (comet) intervention includes brief interactive reading and writing exercises based on cognitive restructuring, behavioral activation, gratitude, and self-compassion (Frontiers in Psychology, 2021). Although the skills are specific enough to relieve symptoms of anxiety and depression—Wasil’s research showed positive effects for up to 3 months—the skills are useful for anyone.
According to Wasil, further integrating mental health interventions in schools could be an effective way to promote long-term well-being in adolescents. “In my ideal society, people would be exposed to psychological principles just like they learn basic arithmetic,” he said. “I think of it as putting evidence-based strategies into the water supply.”
The relationship of SSIs and traditional therapy
Single-session and traditional therapy are different options in an array of psychological interventions, and Lorenzo-Luaces says it’s very unlikely that the availability of SSIs would negatively impact psychologists who provide ongoing psychotherapy. “Mental disorders like depression and anxiety are so prevalent that even if the number of therapy providers doubled overnight, there would still be a shortage,” he said. “So we who develop these interventions think of them as an adjunct.” Further, conditions such as very chronic substance use disorders and more complex mood and personality disorders may not be conducive to the single-session model.
In many cases, single-session interventions go hand in hand with traditional therapy models. As with Schleider’s intervention, SSIs can tide people over with coping skills until ongoing therapy is available. Lorenzo-Luaces adds that single sessions can be used as first-line interventions when resources are limited—like the difference between going to the doctor’s office for a bad cold versus going to the emergency room later with bronchitis or pneumonia.
George Mason University in Fairfax, Virginia, recently implemented a stepped-care model for students, staff, and faculty that puts this type of model in place. Anyone who needs support can do an initial phone call with a psychologist-trained undergraduate student who implements an evidence-based, coping-focused intervention. If the person’s needs aren’t resolved with that session, the student refers them to an intervention called the Brief Assessment–Informed Skills Intervention for COVID-19 (basic), which is delivered by a graduate-level psychology student in one to three sessions. Anyone whose needs exceed that intervention is referred for standard therapy at George Mason’s Center for Psychological Services.
Developed in response to the added uncertainty and pressures caused by the pandemic, the basic model reduces strain on therapists, provides a scalable model for addressing the needs of the community, and also has the potential to reassure people who may be nervous about therapy. “Taking baby steps toward longer-term therapy can reduce people’s fear of seeking support through long-term therapy,” said Keith Renshawopens in new window, PhD, chair of clinical psychology at George Mason.
Wasil believes digital interventions could also help with stigma around therapy, and hopefully prompt people to seek further support if needed—especially for younger adults, who tend to prefer self-help (Primary Care and Community Psychiatry, Vol. 11, No. 2, 2006). Online platforms that teach evidence-based coping skills could be a gateway to therapy, Wasil said, helping people understand what therapy entails and motivating them to seek it out.
Single-session therapy may also occur after a client completes a course of multiple sessions with a therapist. Cynthia Dodge, PhD, a counseling psychologist based in Arizona, offers single-session therapy through her private practice, using CBT, dialectical behavioral therapy, and skills-based interventions to help people cope with personal problems in a 1-hour virtual session. Many of her single-session patients are people who have already attended ongoing psychotherapy but need help with a particular problem without a commitment. “It’s like a booster shot for people who have been through therapy and need help synthesizing the tools and knowledge they’ve already gained,” said Dodge.
Incorporating SSIs into practice
Any clinician can incorporate single-session principles into their practice and there are many resources available, from books to e-courses and other trainings. Windy Dryden, PhD, a London-based clinical psychologist who teaches SSI workshops, says it’s important to incorporate practices from a variety of approaches to best help the patient. “You can ask yourself, if I only have one particular session with this client, how can I use it?”
If you plan to work with particular populations, Bradstreet says that speaking a patient’s cultural language is useful. He developed a “mental fitness model” to help athletes understand psychological principles in terms they’re familiar with. In working with youth, therapists often use technology to facilitate growth.
Understand, too, that single-session interventions aren’t for everyone. Dodge says that she carefully screens potential patients with a questionnaire before offering a single session. For example, she asks them to share what they can control in their lives, and then what they would like to focus on and change, to ensure they have a concern that could be addressed in one session. Generally, she says, people who are motivated to grow in a short amount of time and already know what they’re struggling with do best in this type of therapy.
SSIs may not be as helpful for patients who aren’t clear about the source of their distress, because dissecting a problem in therapy can be time-consuming. In addition, patients who don’t already have a degree of confidence in the therapeutic process before the meeting are also not good candidates for SSIs. For these patients, it may take a number of sessions to develop an orientation to understanding the source of the distress and how psychological principles and strategies could be helpful.
Whether a psychologist does one session or several, the idea is to help people in a way they’re most likely to benefit from. “We’re trying to offer patients the help they want rather than the help we think they need,” said Dryden.
