A Need for Speed?

How Therapists Can Meet a Growing Demand

Magazine Issue
March/April 2020
A group of business-people kneeling at the start of a race

Bob Rosenbaum and his colleagues Moshe Talmon and Michael Hoyt first developed an approach they called Single Session Therapy (SST) in the late 1980s while working at Kaiser Permanente in Oakland, California. After discovering that the most common number of sessions attended by clients at their clinic was not the recommended eight—not even four, nor three, nor two—but one, Talmon decided to call up his clients who hadn’t come back after their first session and ask them why. What he learned—that the vast majority of them were happy with just that single hour—would forever alter his conception of what makes therapy, therapy.

Contrary to what he’d feared, these former clients assured him they hadn’t been turned off by him or his way of working. They hadn’t returned to therapy, they said, because they’d gotten what they needed. After having another clinic employee follow up to ascertain that they weren’t just telling him what they thought he wanted to hear, he teamed up with Hoyt and Rosenbaum to undertake a formal study comparing the outcomes of single-session clients to outcomes of clients who’d decided to come back for more. The results of the two groups were indistinguishable: an 88 percent improvement rate in the symptoms they’d hoped to address. Many reported experiencing positive life changes because of what Rosenbaum describes as “basically getting over a hump and getting on with life.”

So what might it look like to approach therapy with a single-session mentality, operating under the assumption that clients may not come back for another session—and with that in mind, doing as much to help them in that session as possible? Rosenbaum gives the example of an early client he approached with this mindset. Carl, a 23-year-old warehouse worker, who’d come to therapy at his wife’s urging, had never sought help, never talked to anyone about his problems, and in a tone so flat it betrayed his underlying depression, told Rosenbaum he doubted therapy would help. “Well,” Rosenbaum shrugged, “sometimes talking about things can help. Many people who come here find that even one time can help a lot.”

Carl acquiesced and began painting a picture of a life befitting a much older man. He had a wife and child to support, a demanding job, and a feeling of unrelenting pressure that sometimes got so intense he was afraid he might explode. On top of it all, his boss had recently asked him to step up and become a foreman. Sensing that the added responsibility would push him over the edge, Carl turned the promotion down, at which point his boss started assigning him “lousy” tasks, and, most infuriating to Carl, criticizing him for not being a better provider for his family.

When Rosenbaum asked about his family, Carl said though he did feel stressed by his responsibilities, he deeply loved his son. Then Rosenbaum asked Carl about his own father. It turned out his dad had disappeared when Carl was a young boy, but had started turning up to see his grandson, leaving Carl to wonder why he hadn’t come around when he needed him as a child.

Hearing this, Rosenbaum wondered if his anger at his boss could be related to his feelings about his father. He suggested they role-play expressing how he felt to his dad, after which he could decide to actually talk to him, to continue to practice what he might want to say to him, or just absorb what he’d learned from the role-play.

At the end of the hour, Rosenbaum was careful to leave the door open for a next session, which Carl said he’d think about. When he didn’t come back, the clinic followed up. Carl said he was doing better, not feeling as “burdened” or depressed or tense. He’d left his job, was temping as he searched for something new, and was grateful to hear from them, but didn’t feel he needed more therapy.

So what should we make of what did and didn’t happen? Did Carl get enough out of that one session to better handle a rough patch in his life, gain clarity around his stressors, and make clearer decisions? Was more therapy necessary? If you knew ahead of time that Carl wouldn’t return, would you do anything differently?

Unlike other therapists, who might’ve regretted that a client who appeared depressed decided not to return for more therapy, Rosenbaum saw it differently. His guiding principle is to consider what benefits clients can walk away with if a first session is their last. Central to his philosophy is the rejection of the idea that therapy is necessarily a prolonged process, or that therapists have special powers to offer clients possible solutions to their problems that aren’t already within them. Of course, it’s important not to downplay issues that require more time and attention. The door for further, deeper exploration should always be open, but the therapist needn’t feel compelled to usher people through it.

Carl’s session with Rosenbaum happened decades ago, but the recent push in popular culture to destigmatize therapy and raise awareness about mental health means more and more people like him are seeking help. With therapeutic resources in such demand and stretched thin, Single Session Therapy, along with other ultrabrief therapies, are in the spotlight and garnering positive attention. But is it deserved? Can such short interventions really make a difference?

The Urge to Go Fast

Over the years, SST—less a particular therapeutic method than a form of service delivery—has found a foothold around the globe. The founders emphasize the importance of conveying a loving and hopeful attitude with SST, so there’s a positive transference with clients, no matter how anxious, depressed, or demoralized they might be. Zeroing in on what clients most want to address and creating good moments together as you work is twinned with conveying how this work might be consolidated by the clients when they leave. It’s an underlining of the belief that clients have it within themselves to carry on, with or without ongoing help.

Last year at the third international single-session conference in Melbourne, Australia, experienced practitioners from Europe, Asia, and South America dug deep into how to apply a single-session mindset with an array of clients and clinical issues. Talks on implementing SST at times of psychiatric crisis took place alongside a heady workshop from Rosenbaum on the Zen nature of “sudden” versus “gradual” realizations in therapy.

Although single-session options haven’t taken as much of a hold in the United States, that may be changing. With greater—though far from perfect—parity in mental health coverage and an increasingly anxious generation that seems to embrace the value of therapy, the demand for treatment has skyrocketed. In addition to the worried well and the shaky couples who sign up for weeks of sessions with private practitioners, nearly 50 million Americans are now experiencing psychological difficulties. Meanwhile, only a few hundred thousand professionals are available to provide services. The result is that less than half of adults with mental health issues are receiving treatment at all. Whether because of entrenched stigma, shoddy coverage or lack of access, the average delay between the onset of the need for help and finally getting it is 10 years. Plus, with youth suicide having increased by more than half over the last decade or so, and teen depression by more than 60 percent, it’s even harder to ignore the widespread need for mental health services and the importance of briefer, more accessible therapeutic interventions.

Last December, in fact, more than 4,000 therapists and counselors at Kaiser Permanente’s various California offices went on strike to protest severe understaffing in clinics and months-long wait times for clients. The National Union of Healthcare Workers got involved, producing a survey of Kaiser staff that claims 94 percent of therapists disagree with the statement that “weekly individual psychotherapy appointments at your clinic are available to those in need.” Beyond that, practitioners who want to help underserved clients have begun offering hundreds of thousands of pro bono hours of therapy through the Give an Hour nonprofit, which reaches vets, first responders, and survivors of mass shootings, natural disasters, and border incarcerations.

This recognition of the unmet need for mental health services has led some to question traditional approaches to the ongoing therapeutic relationship that so many practitioners hold dear. But as attention turns to developing faster therapy that could free up space on a practitioners’ calendars, troubling questions have emerged. Are we really offering good treatment if we’re so focused on a quick fix for a presenting problem? How ethical is it for us to treat someone with complex issues in this way? And on a basic business level, how will clinicians offering these kinds of ultrabrief therapies be able to support their private practices?

In the last few months, publications like The New York Times, The Atlantic, Scientific American, and Oprah Magazine have offered favorable coverage of microtherapies and SST, with glowing profiles of practitioners who seem to have some solid research on their side and operate more like physicians: offering clients single-visit care with the option to return on their own schedule if needed.

What’s the therapy world to make of this growing trend? “As a field, we’re recognizing that it’s possible a lot more can happen in a single session than many of us were trained to believe,” says Deany Laliotis, the director of training for EMDR Institute, Inc. “Whether it actually happens is not the result of some magical method, but the combining of several factors: the appropriateness of the approach, the skill of the therapist, and the readiness of the client.”

Can this streamlined, more efficient service really address clients’ needs? Today’s ultrabrief therapies come in various forms and address different treatment populations. What follows is a look at some practitioners offering abbreviated treatment approaches: a trauma specialist who claims she’s tweaked EMDR to resolve symptoms in as little as an hour, a clinician who’s turbocharged phobia treatment in kids to three hours, and a young university-based psychologist making waves with a 30-minute online protocol for depressed and anxious kids.

An Hour for Trauma

Back in the early ’90s, Francine Shapiro generated shock waves in the therapy world with an approach called EMDR (Eye Movement Desen­sitization and Reprocessing). It was based on the idea that traumas once thought to take years to treat could be resolved far faster using bilateral stimulation of the brain, usually by waving fingers across a client’s visual field. Critics scoffed, but a large body of outcome research has since established the therapeutic potency of Shapiro’s method.

Now a Connecticut LMFT named Laney Rosenzweig has generated new shockwaves by claiming that by pairing EMDR with methods derived from neurolinguistic programming, she can free people of trauma symptoms, phobias, and a variety of other issues in as little as an hour—though she concedes that complex trauma might take a few sessions more.

Despite some controversy about her approach and the consternation of a few members within the more traditional EMDR community, the Substance Abuse and Mental Health Services Administration has recognized Rosenzweig’s Accelerated Resolution Therapy (ART) as an effective treatment for PTSD, stress, and depression. Kevin Kip, at the University of South Florida, whose research on service members with disabilities is supported by the Department of Defense, has published studies supporting her claims of successfully treating complex trauma without adverse effects within a median of three sessions. She trains therapists at places like Walter Reed and Walden Behavioral Care to use a series of scripts she says will ensure quick, effective healing. No homework or skills practice for clients is required.

In our interview for this article, I told Rosenzweig that I’d had a positive experience with traditional EMDR a while ago. I’d caught typhoid fever while traveling and spent weeks hallucinating in a primitive hospital. It was a disorienting and deeply lonely experience, heightened by a recent romantic breakup, and an unrelenting state of existential dread stayed with me long after I returned home. With my EMDR therapist, I’d recall the frightening hallucinations or the sights and smells of the clinic, and we’d rate the activation in my mind and body before and after the eye movements, exploring the thoughts that arose, including those around the breakup. After a few weeks, my panic attacks subsided, my sense of humor returned, and I was able to sleep again. I felt cured when she told me we were done, as if I’d endured the consistent panic and shame long enough to finally let it go.

But Rosenzweig says I suffered needlessly. She concedes that my therapist focusing on my body’s reactions to the images that still haunted me was good, but that I didn’t need to get caught up in the random negative thoughts, associations, and images the eye movement elicited. “We don’t work with cognitions,” Rosenzweig says. And that difference, she argues, helps curtail much of the meandering that can drag the healing process out.

In the very first session, Rosenzweig’s approach homes in on healing metaphors and positive images that can replace the trauma’s “horrific images.” She cites the case of a nun with an abusive childhood who was having trouble walking. Her replacement image was of balloons tied to her legs that lifted her up and away from the traumatic past she felt she couldn’t leave behind. In this way, Rosenzweig says, the brain gets back into a pretraumatic state of calm that holds even when old knowledge of the events gets triggered. As evidence of the power of her approach, she recalls that when the nun returned to thank her, she took the stairs.

“I was trained in EMDR, but I wasn’t good at it,” she tells me. “I made it more directive because I didn’t like to focus on the free associations therapists were encouraging in the clients. I found it dangerous to do that, because you don’t know where you’re headed, and the eye movements in themselves are so powerful. It’s like using a laser: you have to know where to point it.”

Part of that power, Rosenzweig says, may be in the relationship eye movements have to REM sleep, which she sees as a learning state of dreaming that can create changes. She believes clients can connect to their creativity better when using the eye movements in therapy, just as they might while dreaming. “Sometimes EMDR therapists don’t even start the eye movement component for months because they think they need to develop a deep relationship with their client,” Rosensweig says. “But I don’t think that’s necessary. Personally, I’d rather go to doctors who get results than worry about how much I like them.”

Like many practitioners, trauma specialist and EMDR trainer Linda Curran has some reservations about Rosenzweig’s work. She believes that EMDR, whether modified in ART or not, can create powerful breakthrough for clients with a simple trauma in a single session, but that anything more complex is another story. “Can this be a miraculous cure for the worried well? Can you process their overwhelm and help the symptoms that have accompanied a single incident go away? Sure, like lots of approaches, it’s possible,” Curran says. “However, it’s very rare that someone specializing in EMDR would only see clients with single trauma. More often, it’s clients with complex, developmental, co-occurring disorders who come to offices like mine.”

She emphasizes that with every case, no matter what it is, an assessment is pivotal—that in itself can take more than one session. “What do you know after meeting someone for 45 minutes? If they haven’t had info on how to regulate themselves or a good attachment growing up, if they’ve experienced trauma early and often in their lives, and you haven’t gotten a sense of whether they have the skills to stay stable after an intervention like this and you go forward with it, then you just wind up being the next person who destabilizes them.”

The lack of attention to building a therapeutic relationship, which Rosenzweig credits with accelerating the pace and focus of her approach, is on display in a video she includes in a TED talk. In the recording of the case of a female postal worker mauled by a dog, there’s no discussion of her trauma history. But after a single session of ART, the woman, who hasn’t been able to return to work after the attack, tells Rosenzweig she saw the image of the trauma literally being erased. “It’s gone,” she says, reaching her fingers into the air in front of her, where she used to see the scenes of the attack replay. She confesses she sees another therapist who does exposure therapy, but with not much result.

At the end of each of her ART sessions, Rosenzweig uses a healing metaphor with clients a final time, taking them over a beautiful bridge in their minds to leave the trauma or the problem behind. When we see the postal worker in the video again, Rosenzweig has caught up with her on the job. She’s in front of a porch, clasping a handful of mail, clothed in the signature blue USPS top and shorts. She recounts what happened to her. “I’m out one day, happy, good to be out, and see everybody, and the dog just comes through the door and I’m destroyed. I was in the hospital for a week and a half, three surgeries, physical therapy for two months. . . . It’s an incident that happened to me, but now I have no feelings attached to it.”

Rosenzweig won’t take me step-by-step through what she’s doing in her sessions, nor does she show it in the video. That information is reserved for her trainees and the book of scripts that she puts in their hands. She claims that those scripts go beyond trauma to include ongoing problems like OCD, chronic pain, addiction, depression, anxiety, eating disorders, ADHD symptoms, and dyslexia, all of which she believes have a trauma component but can still be cleared up in very little time.

Her claim—that some of these complicated problems clients have tried to resolve repeatedly in therapy before coming to her can sometimes be treated in a single session—will strain credulity for many. It’s a reaction she’s used to. “I’ve been called a witch by those I’ve worked with,” she says. A beat later she clarifies: “But they say I’m a good witch.”

Single Session and Loving It

There will always be clients who crave the continuity and security of the healing relationship that ongoing therapy can provide. The promise of empathy and warmth to counter isolation, and the idea that therapy might not only deliver them from a presenting problem, but help them resolve a host of issues over time, can be attractive. But the loudest chorus of criticism around abbreviating the therapeutic relationship comes not from clients, but from within the field itself. Is this critique a reflection of therapists’ attachment to the comforts of their traditional methods, which may have more benefit for them then their clients?

Jay Haley, the pioneering family therapist who helped found the strategic model of psychotherapy and popularize the brief and solution-focused movement back in the ’70s, wrote in this magazine that therapists’ hesitation lies not just in the inevitable, consistent scramble for clients that’s part of brief work, but the high level of challenge and skill inherent in working quickly.

Recognized as one of the field’s foremost iconoclasts and a critic of traditional therapy approaches, Haley wrote, “The long-term therapist needs to learn only one method and apply it. The therapist does what he did with the last person. If the client does not get the method, another one will. How much more demanding it is to come up with an innovation or a variation in each case. . . . I once had a brief therapy private practice and to equal the income of the long-term therapist required from three to four times as many referrals.”

Haley also found the work harder, he said, because “the therapist must make the effort to clarify what is wrong and think of something relevant to do, all in an hour. What a contrast that is to a long-term approach where it takes three sessions to complete a history and three more to finish the genogram before one begins to think about how to solve the problem.”

Even today, for most approaches of psychotherapy to have any effect, it’s believed the client and the therapist need to put in extended time together. At the very least, the therapist needs to be able to gather information, have time to formulate a plan, and meet regularly enough to see how that plan is playing out. And then there are the often cited “common factors” considered by some to be essential to any therapeutic intervention: the healing setting, the interest in framing and explaining clients’ problems in a way that conveys a sense of hope and the possibility of change, and a kind of “ritual enactment that therapist and client both believe will restore the client to functioning well.”

Bob Rosenbaum insists that even in very short therapy, like SST, there is a connection with the client and that, in fact, many common factors are in play, whatever a therapist’s orientation. And he believes that other countries often adopt microtherapies more readily than the United States because they’re freer to think of therapy as a punctuated relationship, not an ongoing one. If a therapy visit is like checking in with your doctor, you go in expecting that what you need to heal at that time may be provided in that one sitting.

While testing whether clients could believe such a possibility, he and his Kaiser colleagues used a script that he sums up as: “We’ve recently found that a lot of people seem to get what they need in one session. I don’t know if that will be true for you, and we’ll do whatever’s needed for you, but I’m willing to work hard today to get as much done as possible and maybe even everything you need. Would you like to work at that?”

Nearly everyone said, sure, let’s give it a try—except for one group of people. “Can you guess who it was?” he asks. I can’t. “Therapists,” he tells me. “Not people with complex disorders, not narcissists . . . therapists!” Rosenbaum thinks that in addition to their deeply entrenched beliefs about healing taking time, therapists don’t often grasp the profundity of what they offer people simply by focusing on them, even briefly. “We forget that most people have never had another person listen to them with undivided attention and compassion for 15 minutes, let alone 45 minutes. It can actually be quite transformative.”

But critics have countered that many clients have a larger appetite for that transformation than others. Maybe they want to know more about themselves or interrupt lifelong relationship or work patterns that other therapies haven’t helped them examine. If suicidal ideation is active or psychosis is in play, they’ll need more than one session, whether you offer it to them or not.

Rosenbaum informs me that, surprisingly, suicidal and psychotic clients often do benefit from a single session. He argues that with all clients the goal is not to require them to keep coming back. It’s to invite them back after working hard with them the first time, and if they’re not actively a danger to themselves or others, to leave it up to them to accept or decline that invitation.

Part of the marked increase in interest in SST over the last few years has come from American college counseling centers, which have called Rosenbaum to help them address a full-press from parents and administrators to treat an ever-increasing number of students with psychological concerns. There’s been a push for these centers to embrace a kind of urgent care model with same-day scheduling and concise sessions to meet student needs. Oregon State has recently started offering single sessions for students who aren’t interested in ongoing services but would like to deal with a current problem, while maintaining a traditional ongoing counseling setup for others. The University of Delaware offers single-session counseling for students with what they define as “discrete,” rather than “chronic,” issues. Amherst College lets students know they can “more quickly access a counselor to address issues and concerns causing distress.”

Speeding Up with Kids

Troubled college kids, young adults, teens, or children, all with their special vulnerabilities, can add a true sense of urgency to the long-or-short therapy dilemma. There are those competing desires to ease young ones’ suffering quickly and to not push them beyond what their still-developing minds can handle. But for two of the micropractitioners I spoke with who work with kids, the growing need they see in this population, and the knowledge that they can meet a larger portion of it if they work quickly, has made it an easy decision.

Someone like Rosenzweig minimizing the role of strong relationships in therapy would’ve once been anathema to psychodynamically trained psychologist Thomas Ollendick, who, as a young practitioner, had been taught conscientious therapists should meet hundreds of times with clients. But Ollendick soon found his training of such little use with the inpatient kids with autism who were his first professional clients that he turned toward more practical interventions and never looked back.

Now the director of the Virginia Tech Child Study Center, Ollendick, in conjunction with a Swedish professor named Lars-Göran Öst, is in the spotlight for having refined an ultrafast protocol for treating phobias in children. Their therapy is so focused it revolves around a single, in vivo session lasting three hours.

As opposed to treatment for something like trauma, many therapists who specialize in phobia no longer feel the need to analyze what may have triggered the problem initially but are happy to proceed with nixing it. Still, one session for many clinicians is pushing the envelope. The in vivo phobia treatment Ollendick practices can be challenging—some might say terrifying—to endure, so it’s commonly spread out over a series of sessions, even with adults. Initiating the treatment with kids, some have protested, is an ethical quagmire. Can a child truly consent to confronting something that scares them so profoundly? Can a practitioner explain the process to them in a way they’ll unquestionably understand? But Ollendick believes that phobic children actually have a leg up on adults who share their fears: a malleability in their still developing brains that supports working fast. And he assures me his form of exposure is gentle in its own way, despite the accelerated time frame.

The kids he sees are commonly terrified of dogs, the dark, heights, airplanes, and costumed characters. The treatment bookends the three-hour exposure session with a lengthy initial assessment over the phone, and four, 10 to 15-minute follow-up maintenance calls in the week that follows. “We begin delicately with a lot of alliance building. We’re not cruel, even though we’ll be exposing people to what they’re afraid of.”

The three-hour session begins with a behavioral approach test. For children with dog phobias, for instance, that might be a dog on a leash inside a room. The child is told to please walk into the room, where, in the back corner, she’ll find this dog. She’s asked to pet it for 10 seconds. “Most can’t go in,” Ollendick explains. So he shows them pictures of dogs instead, moving on to videos that inform them about dogs and their typical behavior. Then one of his researchers takes the child back to the door and models approaching the dog while the child enters the room alongside him, maybe putting a hand on his shoulder at first. The next step, which might take a few trips in, is the child moving her hand closer, maybe to his forearm as he pets or feeds the dog, then eventually onto his hand.

“Most kids think something bad will happen if they approach a dog, so we’re always testing their beliefs: What’s happening now? What did the dog do? They begin to see how the dog behaves and get lots of positive reinforcement from us about staying in the room and progressively approaching it. We’re doing graduated exposure here with a hierarchy of 15 steps. The final step will be feeding a dog by hand.”

Ollendick’s three hours can end with dogs munching on the food in a child’s cupped palm, spiders crawling on hands and in laps, and kids making it to the tops of high ladders, riding in elevators or sitting in an airplane. His success rate isn’t perfect, but it’s good: about 60 percent of the children ditch the phobia by the end of the single session. At a one-year follow-up, that percent jumps to 75, or higher if there’s parental encouragement and reinforcement over time. These numbers aren’t so different from longer-term standard CBT outcomes with anxiety disorders in kids, which he and Öst showed with a meta-analysis comparing work like theirs to longer-term interventions.

Ollendick knows he works in a unique setting with a specific clinical issue, but he wishes every therapist working with this population could have the same quick results he does with so many clients. His clinical work is research, so it’s fully funded, and he doesn’t have to support himself in private practice. But he’s driven by an acute awareness that the way we currently conduct treatment with anxious and debilitatingly phobic kids—who often come to him after years of expensive traditional therapy—isn’t working.

Therapy Substitution?

Beyond phobias, reaching suffering kids quickly has long been a problem in therapy. Unlike adults, teens and children can’t take themselves to a therapist when their moods crash. But efforts to reach them where they are—in schools and online—through psychoeducation and, more recently, smartphone apps, are ramping up. Most apps are for teens, but meditation and positivity apps are available for children as young as five.

Ollendick swims in the same research waters as Stony Brook University professor Jessica Schleider, whose rapid online interventions for anxiety and depression have gotten her a slew of attention, including a spot on this year’s Forbes list of “30 Under 30.” Unlike mental health apps, Schleider’s online, single-session interventions don’t require a phone and are free to the public and even to other researchers. Given that nearly 80 percent of kids in this country never get the therapy they need, it’s part of her philosophy that interventions should have a wide reach. And though she has respect for clinicians offering ongoing therapy, she’s motivated to find ways to get briefer options like hers into existing systems that serve kids.

“One avenue is through primary care where kids might be screened for a mental health issue. Another is schools,” she says. “Our goal is not to replace therapy: it’s to reach people who are failing to access treatment. That’s why we’re creating something that can be accessed anywhere and fit in wherever there’s a gap in services.”

When I ask her about limits on the effectiveness of mental health apps currently marketed for young clients, she explains that the uptake of the information contained in the apps, at least among young people, isn’t so hot. “They’re meant to be downloaded and then checked in with and worked with on a daily basis, but virtually no one does that,” she says. Instead, they’ll often interact with them at the same rate as Rosenbaum’s in-person clients did at Kaiser: one time.

It further strengthens the reason Schleider and her team have taken a page from SST: packing her super short interventions with what she hopes will be a lasting and powerful punch, while underscoring kids’ own ability to heal. “We teach people that they’re capable of change, which is a transdiagnostic issue. We target self-hate through an intervention that increases self-compassion, and we target changing behavior so there will be an increase of pleasant activities.”

In the 30 minutes the kids are interacting with Schleider’s program, she targets beliefs that often underlie depression and anxiety. But Schleider has added an element to help lock in the effects of this quick process: participants are asked to help someone suffering the way they are by agreeing to pass along what they’ve learned through the intervention.

“In most treatment, people expect to get answers,” she says. “We flip the frame for single sessions with an invitation for them to help us. Putting a kid in a helper role imparts a sense of agency, control, and mastery. Understanding that they have a lot to contribute and share can be an entree to well-being and a huge way to boost mood.”

Schleider encourages me to head to schleiderlab.org/yes and try it out. I choose an option called Project Personality, drawn to its cheerful illustration of a brain lighting up with smears of color, and a tag that reads “learn about your power to grow and change in ways that matter to you!” My first task is to fill out a “not true, sometimes true, or true” checklist about feelings I’ve had. It reads a bit like a depression scale: “I felt miserable,” “didn’t enjoy anything,” ”was so tired I just sat around and did nothing.” There’s more about feeling restless and unloved and not as good as other kids.

What follows is an instruction to adopt a here-and-now mindset and then answer some questions about projecting feelings into the future, like “the future is hopeless and can’t improve,” “things just can’t work out the way I want them to,” “there’s no use trying to get what I want because I probably won’t get it.” The third checklist has a more positive bent, as I’m prompted to enter my true-or-not checks for statements like, “If I were to face a big problem, I could think of many ways to get out of it,” “I’m now energetically working toward my goals,” “I see myself as being pretty successful,” and so on.

I’m sucked in. “Am I working toward my goals energetically?” I wonder. Great question. Related lists pop up that vary between prompting me to rate how I identify with negative and hopeful statements, until I come to a page where I’m asked to put on headphones and listen to stories from scientists and kids like me.

I first get a basic neuropsychology lesson, where I learn that I’m not stuck being a certain kind of person. Instead, I do the things I do because of the thoughts and feelings I have, which may originate in the brain but aren’t set in stone. This is because brains are made of neurons that form the connections that generate my thoughts and feelings. And those thoughts and feelings—like “I’m a loser and I’ll never make friends in school”—can lead to actions, like staying in bed instead of going to class. But if I start to act differently, I’ll start to form new connections between my neurons, and my personality could change.

To cement this idea of personality malleability, I’m introduced to that reliable Psych 101 character Phineas Gage, a railroad foreman who went from being kind and ethical to boastful and violent after a three-foot tamping iron entered his cheek and bored through his brain. The people who knew Gage were shocked at the shift in his personality. But after he returned to doing disciplined, consistent work, as a driver and farmer this time, his better attributes prevailed, and he was able to live out the rest of his life as an upstanding person once again. Just like Gage, kids can change, too. Bullies can go through programs that teach them new ways of thinking and grow new connections in their brain that lead them to become more compassionate. Sad and lonely kids can make friends and become content.

Next, I’m prompted to share my point of view about why a new kid in class might be shy at the start of the year but not the end of the year. Later, I’m asked to help other students by sharing my own stories and advice about how I might feel about being ignored by a friend in school, and how I might advise someone in that position. I’m then asked again to rank my own feelings and sense of ability to solve problems, as well as give advice to someone struggling with depression and anxiety.

Adolescence is a fuzzy memory for me, but these themes of perceived rejection and our own ability to maintain or create a more positive mindset are real enough that I end the half-hour feeling that kids might very well benefit from this in a real, if temporary, way. After all, I have! It’s an effective, well-constructed combination: the questioning, the unforgettable example of Gage, the sense of purposeful dissemination of what I’ve learned. And I can easily imagine schools and other institutions adopting it for all kids to engage with as a kind of mental health primer.

And yet for kids who are truly suffering, it’s so short. Yes, it may be a potent introduction to how to shift depressive thoughts and behaviors, but if it was all a kid got by way of treatment, would it really stand up to the emotional challenges of adolescence? To a harrowing family life? To someone too disheartened to take action?

Schleider is working on developing more for these kids with other interventions she’s testing, like immersive and engaging virtual reality experiences. She’s not promoting these as one-and-done interventions. She assures me they do their best to provide referrals where they can, and presumably schools and institutions would do the same.

Time, Time, Time . . .

If the field is to embrace a future where seeing a therapist is just as common as seeing a primary care doctor, then we need to ask ourselves if the way we organize practices now—mainly with weekly meetings for months or even years—meets the greater societal need for care. Will our clients continue to believe in the value of the long-term therapeutic relationship if working faster gains a foothold?

The four innovators I spoke with have all been willing to challenge the ideal of a certain kind of private practice therapy delivery—individual, open-ended, expensive—and chink out pinholes of light for the millions of would-be clients who can’t find quick relief or even an appointment with a therapist.

Rosenbaum likes to talk philosophically when urging the field to reconsider its entrenched notions of how long it takes to heal. From his perspective, “change doesn’t take time, change is time—sometimes it matches clock time, and sometimes it just doesn’t. This idea of a rigid schedule fitting everyone is nuts,” he says. “It’s an accounting tool. It doesn’t respect the variety of organic change that can happen.”

Rosenbaum likes to ask therapists if they’ve ever seen a client have an eye-opening insight 20 minutes into a session. Most therapists say, sure. “And then what do you do?” he asks them.

Therapists tell him they go on, thinking they can get more accomplished in the remaining half-hour, but Rosenbaum says that’s a mistake. “As a neuropsychologist, I can say definitively that people remember things at the beginning and end of sessions better than the middle. In my practice, when a client has that insight after 20 minutes, I’ll say, ‘In my experience, talking about that more right now might dilute it. I think you need more time to absorb it. How would you like to do that? We can sit here silently, we can stop, you can take a walk, you can call someone. What would you like to do?’ I’ve never had a client say, ‘But you owe me this time!’ Just because a session is over doesn’t mean that healing ends. In fact, I usually recommend people stop five minutes earlier than they think they should. It gives them the room to consider, ‘What’s gonna happen now? Where does this need to go?’” Rosenbaum believes it behooves us to understand that the answer may not be to come in for more sessions.

In the early days, when he and his colleagues first hatched their plan to study the potential of single sessions, he was still uneasy about one session delivering anything close to what he was trained to offer in a dozen or more. Around that time, he took a solo vacation to clear his head and try to shake the sense that they were setting out on a fool’s errand.

“I went on a hike in the Sierras,” he recalls. “I was saying to myself, ‘Okay, I was trained psychoanalytically, and then I trained psychodynamically, and then I was in community clinics and learned 20-session psychotherapies, and then I learned 12-session psychotherapies, and at Kaiser I’m aiming for eight sessions. But one session?! C’mon, that’s impossible!’ Then I looked out at my surroundings and thought, ‘People are like these mountains: they change slowly, over years and years.’ But just as I thought that, I turned a corner and saw an avalanche chute where the entire face of the mountain had changed in 30 seconds!”

What would happen if we began to see clients as Rosenbaum saw that mountain? Would aiming to offer them treatments that might help them profoundly within hours or days benefit not only both of us, but the many, many more potential clients hoping they too can walk through our doors? If we start thinking this way, where does that leave the seemingly indisputable research about the importance of the ongoing therapeutic relationship?

It’s something to ponder. At least for the length of a single session.


Photo Credits ©istock.skynesher; ©istock.delmaine donson; ©istock.sutin lodthong

Lauren Dockett

Lauren Dockett, MS, is Psychotherapy Networker’s senior writer. A longtime journalist, journalism lecturer, and book and magazine editor, she’s also a former caseworker taken with the complexity of mental health, who finds the ongoing evolution of the therapy field and its broadening reach an engrossing story.  Prior to the Networker, she contributed to many outlets, including The Washington Post, NPR, and Salon. Her books include Facing 30, Sex Talk, and The Deepest Blue.  Visit her website at laurendockett.com.