In recent years, the One-at-a-time (OAAT) approach has gained momentum as a way of working in university counselling services. It can potentially allow a lot of clients to be seen, increasing throughput, reducing waiting lists and encouraging client independence and autonomy. Instead of picking up new clients when a counselling contract has ended, this approach means a counsellor sees a constant and regular stream of new clients each week.
If I think about it in terms of numbers, it means a counsellor working three days a week (seeing two new clients out of five appointments per working day) could see six new clients a week, or 24 a month. The same counsellor working at an up-to-four weekly session patterns could see 15 new clients a month. Multiply this by the number of counsellors working in the service, and the numbers of new clients being seen could increase quite significantly with the OAAT approach, thus reducing waiting lists and increasing throughput.
A colleague likened OAAT working in Higher Education (HE) to a one-night stand, which made me laugh and got me thinking. It is a one-off, you may never see this person again and it can be freeing and liberating because of that. However, there are limitations for client and counsellor because it’s not necessarily about building a long-term relationship, and endings are somewhat different to how I was trained to work with them.
After the lockdowns of the pandemic and then a move to hybrid working in 2021, I took the decision to commit to the OAAT approach for the academic year 2021-2022. For me, there had been a gradual move towards this way of working over the last two to three years within a person-centred approach. Now I was curious to see how it would settle with me to fully commit to OAAT working in my HE client work.
The approach emerged out of the work of Hoyt1 and Hoyt & Talmon.2 Dryden3,4 has also practised in the single-session model and written extensively about it. It is exactly how it is described, in that sessions are scheduled one at a time with no presumption that another session will take place.
In a large, embedded and oversubscribed, university counselling service, the OAAT approach is appealing in terms of maintaining throughput, but how does it feel for the practitioner in reality? Is it a liberating one-night stand-like experience? Does it place limitations on relationship building and does that matter?
When I started working one-at-a-time, my client and I would decide at the end of the first appointment whether another was needed. If it was, we would schedule it and if not they were told they could contact the service again if they needed another session. Appointments were not likely to be regular weekly appointments. An intermittent scheduling, anywhere from three to six weeks, was more likely, given client demand, our staff resources and my availability.
This meant a client would have their first appointment with me and while a second appointment was possible it was not the automatic outcome. I consolidated my approach by taking an active role in the decision-making around a second appointment. Where another appointment was not needed I would be explicit with the client about being able to make contact again to schedule another and how to do this. I would also manage expectations around when that appointment could be.
Support from my Head of Service at the time gave me the trust and autonomy to try out this approach and discuss things with them as I went along. External and internal supervision was also important and I could not have got through the year without my excellent supervisor and the peer supervision available to me. They gave me regular spaces to review how the work was progressing. I could be honest about reaching my limits or feeling OK with the work and what was going well or not with this approach. I could be asked questions and had space to reflect on the work with clients and the OAAT approach.
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Inevitably, I learnt a great deal over the past academic year by committing to this approach. OAAT working in HE is demanding and exhausting. There are a lot of new clients to see, client information to absorb, and an increased pressure on the first appointment to get it right because there might not be another. Reflective time could feel squeezed between seeing clients, maintaining administrative duties, other work responsibilities and maintaining a personal life. It kept me on my toes and I was really pushed with this approach. It could feel relentless at times. Occasionally I did miss the development of a relationship over weekly sessions and, at other times, I would marvel at the relationship built with a client over a six-to-nine-month period with intermittent appointments.
It became about managing my diary as much as it was about the client work and sometimes, I wasn’t sure if it was OK for the client or for me. Was I working in a way that fitted ethically with my person-centred orientation? I would question how much of the work was really client-led with this approach, and how much was being organisationally led to reduce waiting lists and waiting times between appointments. At what cost was this approach to me and my relationship with my clients? Was I solid enough in sessions so there was opportunity for relational depth in the moment with my client or was I distracted with the weight of my client caseload? Without flexibility in the diary, support from other colleagues, good supervision and regular breaks, I feel OAAT working can quickly become unsustainable for a counsellor and lead to burnout.
This approach puts more onus on my clients to take responsibility for their appointment in terms of what we discuss and how it is used. Another appointment is not guaranteed or might not be available for another three weeks, so we had to ensure they got as much as they needed from the session. Also, clients had to contact when they needed an appointment rather than assuming they would have another the following week. For the young adult population I predominantly work with, for some, this is a good thing for developing their independence and reflective capacity. They have to consider their level of need for counselling and what they can do to get these needs met. It also means missing an appointment does not result in a quickly rescheduled appointment so they do need to prioritise their appointment or cancel it so someone else can use it.
While OAAT puts more onus on my clients to take responsibility, this was scary for me. My predominant fear and a cause of stress with this approach was, ‘what if I missed something?’, ‘what if the client needed more time than the first session to tell me what was happening for them?’, ‘what if a more regular piece of work is better for my client?’. It became necessary to accept this fear and stress, and trust my instincts and experience to mitigate them. Agreeing email check-ins and emailing resources to clients were important tools for me. Or, if something stuck around after a session with a client, I would reflect on it, perhaps discuss it with a colleague or in supervision, and, if I felt it was needed, email the client with additional resources, signposting options or other pertinent support materials.
Even when sessions were offered more regularly, I had to contend with this risk of missing something such as suicidal ideation or self-harm, so what was different here? The management of risks like this are different with OAAT and more heightened due to the intermittent nature of appointments and reliance on the client to contact. This is another reason why OAAT is so exhausting. So much energy and assessment goes into appointments – from building rapport, to asking questions and working out where to go from there and reading all the non-verbal messages and assessing risk of harm to self or others. Using extended assessment appointments is something I didn’t do but may consider doing more if I feel it is appropriate.
Working with intermittent sessions meant that I considered how much I challenge a client in a session, especially the first one. However, I could also reflect on why I think that I can’t challenge in the first session. Time constraints are a consideration – perhaps I feel there isn’t enough solidity in the relationship for the client to handle it, or maybe I am fearful of getting it wrong for my client. Perhaps there is a way for me to communicate and plant seeds of challenge, to micro-challenge, that would allow the client to reflect on it away from the counselling space? So, whether I do or don’t challenge, I am making an assessment, taking a calculated risk and having to trust my experience and instincts.
Maintaining my case notes each day became very important as I could not retain information about all my clients. I was now seeing more new clients and not regularly enough to keep them fresh in my mind, so I needed to become more efficient at keeping my records up to date. I also had to ensure I had sufficient time in my diary for the administrative work required day to day and any other responsibilities in my role.
The OAAT approach in HE challenges the idea of how a therapeutic relationship is developed. A therapeutic relationship can and does still develop but not in the traditional weekly sessions over a set period of time. If it does develop, it tends to occur over a longer period with longer breaks between sessions. The relationship that is created is neither better or worse – simply different to one that is developed over weekly sessions.
The OAAT approach can be a good way of working with the young adult population who we predominantly see in universities. Their developmental stage and the autonomy and independence that we are aiming to facilitate underpins this approach. The OAAT approach asks practitioner and client to collaborate in consideration of client need – what is it they need today? How can the client get what they need today? Does the client need another appointment? Finding a focus quickly can structure the session in a different way to collaborations that occur in weekly short- and longer-term work. My hope is that if the client can have a good enough experience of counselling in their one session with me, they can and will contact for counselling again when they need another. Even if this is after they have left university and seek counselling elsewhere.
This is not a one-size-fits-all approach, and it was helpful for me to hold this in mind. Where this way of working does not fit with a client’s presentation (and this will happen sometimes), I considered alternative options: workshops and therapeutic groups; external low-cost or free counselling; NHS Talking Therapies for Anxiety and Depression (previously known as IAPT); the University’s Mental Health Advisory Service; private therapy, and whether my own caseload had capacity for a regular counselling contract, to see what could be realistically offered. In the main I have found that HE students respond well to this approach given their busy academic and social schedules. The majority of clients in our service (79.57%) attend between one and three appointments. My take on this is that they too have other competing demands on their time and may not have the capacity for regular weekly sessions, so fitting it in when they can and getting the most out of the sessions can work well. However, continuous evaluation is important and listening to our clients and their feedback of this approach is necessary.
During this 2022-2023 academic year, our service has tried to listen to feedback from students and from within the service. We have implemented changes to support counsellors with this approach. Changes instigated include moving from a student self-referral via our webpage to a referralonly service via our other wellbeing support services (Support & Wellbeing team, GP, Residential Experience team, Mental Health Advisors, Disability team) that the student contacts first for referral; providing more written guidance to staff about this approach (particularly new staff), reducing the number of new client initial appointments each counsellor is required to offer, and aiming to reduce the time between appointments for clients to no more than three weeks. These changes have helped me to feel that my caseload and diary are more manageable and therefore sustainable.
In an ideal HE counselling world, each client would receive the counselling that best suits them. The flexibility of the OAAT approach in principle could allow for this. Those clients who need another appointment could get one in a timely fashion. Those who do not want another can get one when, or if, they need it. The reality at the HE counselling service I work in however, is that demand significantly outstrips resources. Year on year, like many HE counselling services in the UK and beyond, demand increases with or without the corresponding increase in counselling staff resource. This means it isn’t always possible to offer as much counselling and in as timely a manner as I or the client would like. This can make OAAT difficult to maintain. Caseloads can balloon under this approach unless clear cut-off points for seeing new clients are made (whether that is in terms of the number of new client appointments scheduled per day, or the number of clients on a counsellor’s caseload).
Like any approach to working with clients it takes time, trial, error and reflection to develop an approach the practitioner feels comfortable with. Each counsellor’s journey with OAAT will be different. I do think it can work in an HE setting, provided it is not seen as a cure-all for decreasing waiting lists and increasing throughput of clients. It is a way of working like any other – with pros, cons and imperfections. At times I really battled with the approach and was frustrated by my journey with it and, at other times, it really was quite enjoyable – seeing the difference one appointment made for my client, whom I may not see again.
I guess in some respects it really can be like having one-night stands! I did learn that I needed a counterbalance to the quick, intermittent and sometimes frenetic pace of OAAT working in HE. I found some of this balance in the group work I did and with the longer-term clients who I have now worked with intermittently across an academic year and will continue to work with, intermittently, into the next year.
1. Hoyt M. In A. Slive & M. Bobele (Eds.) When one hour is all you have: effective therapy for walk-in clients (pp. xix–xv). Phoenix AZ: Zeig, Tucker & Theisen; 2011.
2. Hoyt M. & Talmon M (Eds.) Capturing the moment: single session therapy and walk-in services. Bethel, CT: Crown House Publishing; 2014.
3. Dryden W. Single session one-at-at-time therapy: a rational emotive behaviour therapy approach. Abingdon, Oxon: Routledge; 2019.
4. Dryden W. Single session one-at-a-time therapy: a personal approach. [Online.] Australian and New Zealand Journal of Family Therapy 2020; 41: 283–301. https:// doi:10.1002/anzf.1424 (accessed 3 March 2023).