1.1 Expectation
A number of years ago I heard Steve de Shazer talk about a research project they carried out at the Brief Family Therapy Center of Milwaukee. They did a lot of research, and their clients were anyone who walked into their office. Being located in the inner city meant their clients were diverse and frequently difficult to work with. The particular research I cite here had to do with the expectation of the client. There was an intake form to be filled out. The receptionist, when looking over the form, said to the client something like, āOh, from what you have written here it usually takes our staff about five sessions to help people.ā The next client would be told ten sessions. The staff were not told about this, that is, they did not know which client was told five and which ten, and they did not know that this was going on. (After all, the receptionist really had no idea of how many sessions a particular client would need based on what they had written!) About one year later the staff were informed about this project and were asked to look at their notes for their clients. They were specifically asked about how many sessions they had with each client, and when the client started doing āsignificantā work. The results were fascinating in that the clients who were told five sessions typically started doing significant change work around the fourth session, and the ones told ten sessions around the eighth or ninth session. Note that the therapists did not all work the same way, i.e., from the same theoretical or practical orientations. The conclusion that the researchers (and I) drew from this experiment is that the expectation of the client plays a major role in how effective therapy is, and how many sessions are needed.
As a scientist it seemed to me that if I graphed these results and the clients were told one session that this would make a significant impact on how fast you could do effective therapy. So, I tell all of my clients that my expectation is that we will be able to do significant change work in the first session, and that I work as if every session were the last one. I also tell them that the decision to return is theirs, and I will always schedule another appointment at their request. I rarely see clients more than one time. Since I work for myself my sessions are always open-ended: the average length of a session is about 90 minutes.
There is a great deal of literature on single-session therapy (SST) and very brief therapy. The first book in this area was the one by Talmon (1990); the subtitle was Maximizing the Effect of the First (and Often Only) Therapeutic Encounter. Talmon worked at Kaiser Permanente in the San Francisco Bay Area and studied with Michael Hoyt and Robert Rosenbaum the work of some 30 psychiatrists, psychologists, and social workers for a 12-month period. Here are the significant results:
ā¢To the best of my knowledge, the āfounderā of single-session therapy (SST) was none other than Sigmund Freud, better known as the founder of the longest form of psychotherapy, psychoanalysis. At the end of the nineteenth century, Freud treated a patient known as Katharina in a single session during one of his vacations on an Austrian mountaintop. Later, he reported to have cured the composer Gustav Mahlerās impotence during a single long walk in the woods. (p. 3)
ā¢When I studied the data, I was astonished by what I found: (1) the modal (most frequent) length of therapy for every one of the therapists was a single session, and (2) 30 per cent of all patients chose to come for only one session in a period of one year. (p. 7)
ā¢ā¦ the therapeutic orientation of the therapists had no impact on the percentage of SSTs in their total practice. (p. 7)
ā¢I later studied 100,000 scheduled outpatient appointments during a five-year period (1983ā1088) and found the frequency of SSTs to be extremely consistent. (p. 7)
ā¢Of all of the SST patients contacted, 88 per cent reported either āmuch improvementā or āimprovementā since the session (on a five-point scale); ā¦ and 65 per cent reported either having positive changes that were clearly unrelated to the presenting problem and might be attributed to a ripple effect. The SST patients showed slightly more improvement and more satisfaction than the patients who were seen for more therapy, but the differences were not significant. (p. 16)
The subsequent book edited by Hoyt and Talmon (2014) entitled Capturing the Moment. Single Session Therapy and Walk-in Services contains some 25 chapters by authors working in these fields. This is a treasure of information on the current status of the SST field. Interestingly, there are descriptions of walk-in single session facilities in Canada, the United States, Mexico, Australia, China, Sweden, Haiti, Italy, and Cambodia. Another recent book, Single-Session Therapy by Walk-in or Appointment (edited by Hoyt, Bobele, Slive, Young, & Talmon, 2018) provides even more evidence that brief and single-session therapies work. A related and useful book is the one by Hoyt (2009) entitled Brief Psychotherapies. Principles & Practices. The more recent book by Hoyt (2017) is entitled Brief Therapy and Beyond. Stories, Language, Love, Hope, and Time.1
In the next section I write about how the essence of SSTāexpectationāis based on the placebo effect.
1.2 The Placebo Effect
The essence of how the placebo effect works is via the expectation of the listener or receiver that whatever is being said or being done will be effective. In fact, the history of healing and curing (distinctions made later) is the history of the placebo effect. In prehistoric times (and continuing to the present in various cultures) mental or physical illness was believed to be caused by the mind or the body being āpossessedā by evil spirits. Thus, you can find skulls with holes drilled in them from prehistoric times. The belief then was that by drilling a hole in the skull (trephining) that the evil spirit would be let out. For physical ailments, the causing agent (or spirit) would be removed from the body by: bloodletting, purgatives, sudorifics (cause or increase sweating), emetics and enemas, or cupping (attaching heated glass cups to the backāthese cups can still be purchased online!). In the recent movie Victoria and Abdul Queen Victoriaās physician frequently asks for stool samples so he can study them. Not too long ago there were advocates of ācolonic cleansingā to cure cancers. On the other hand, the modern medical practice of doing urine and blood analyses and tests of fecal samples are backed up with scientific studies that show that these tests can and do provide useful medical information. There are many cultures and religions who practiced various versions of exorcism for both mental and physical ailments. All of these methods depend on the belief and expectation of both the practitioners and the patients that these ācleansingsā are effective.
There is a vast literature on the placebo effect, and I am only going to cite one source here (and a few more in the section on the nocebo effect): Shapiro and Shapiro (1997). (Chapter 4 in my book on guided imagery [Battino (2000)] is on the placebo effect.) The word ā placebo,ā Latin for āI will please.ā dates back to a Latin translation of the Bible by St Jerome. Shapiro and Shapiroās preferred definition (p. 41) is:
The Shapiros have categorically stated that until recently the history of Western medicine (physical and mental) has been the history of the placebo effect. That is, it was not until the 1950s that there were double-blind studies for physical effects. It has long been known, of course, that opium was useful for controlling pain. However, the purity and dosage of this substance was not studied clinically until the 1950s and later. There was also a great deal of folk medicine that was used, and that appeared to help people. In the history of the development of folk cures many people got ill or died from experimenting! It appears that humans are predisposed to the belief that healers will be helpful (this belief, of course, is useful to all healers, medical and psychological and religious).
There are various factors that enhance the placebo effect in medicine. It has been shown, for example, that if you take the āstandardā size of a pill to be that of an aspirin, that both smaller and larger placebo pills have been found to be more effective simply due to their size. In addition, placebo injections are more effective than pills. Pharmaceutical companies have sold (and still sell) placebos for medical purposes in many sizes, colors, and shapes. When a new drug or procedure is introduced, the publicity (and enthusiasm of the purveyors) leads to that treatment to be more effective initially, and decreases as time moves on. The U.S. is only one of two āadvancedā countries (the other is New Zealand) that permits the advertising of prescription medicines on TV. The TV ads have to include warnings about side effectsāif you listen to the horrors that can possibly ensue from taking that new medicine, no one in their right mind would take it or ask their doctor to prescribe it! Sadly, these ads appear to be effective in promoting those meds, possibly because viewers pay more attention to the lively and active actors who have presumably taken that medicine!
It has only been in recent times that psychotherapeutic methods have been studied carefully enough to have some of them shown to be clinically effective. Wikipedia, for example, states the following about cognitive behavioral therapy:
The practitioners of āevidence-basedā methods have an advantage in working with clients in that they can cite this, thus implying an expectation that this method is more effective than other methods. In addition, insurance coverage appears to favor evidence-based approaches. Perhaps, the bottom line here is that the therapistās expectation (however communicated to a client) helps outcomes.
1.3 Other and Related Expectational Phenomena
Hahn (1997) has written about the nocebo effect where expectation is used to harm people. Two quotes follow:
ā¢The nocebo effect is the causation of sickness (or death) by expectation of sickness (or death) and by associated emotional states. There are two forms of the nocebo effect. In the specific form, the subject experiences a particular negative outcome and that outcome subsequently occurs. ā¦ In the generic form, subjects have vague negative expectations. (p. 56)
ā¢The nocebo phenomenon is a little-recognized facet of culture that may be responsible for a substantial variety of pathology around the world. However, the extent of the phenomenon is not yet known, and evidence is piecemeal and ambiguous. (p. 71)
Commonly known examples of the nocebo effect are in ā voodooā deaths, and the Australian Aborigine practice of āpointing the bone.ā In addition, many cultures contain nocebos i...
