Arnold Slive and Monte Bobele

May 2018
In book: Single-Session Therapy by Walk-In or Appointment (pp.27-39)

By tradition, psychotherapy services have been delivered on a by-appointment basis, whether those services take place in a private practice or in a publicly-funded mental-health agency.
This is how a first session of psychotherapy is commonly arranged in a counseling agency:

• The client decides to talk to a mental-health professional;
• The client calls the agency requesting an appointment;
• The client gets an immediate response or leaves a message requesting a
  return call;
• The client speaks by phone to the receptionist or intake person (same day or
  days later);
• A meeting for an “intake” is arranged; this could occur shortly after the first
  telephone conversation or even days or weeks later;
• The intake process often requires the completion of intake forms and a
  meeting with an agency therapist or intake specialist during which the client’s issues and concerns are discussed. In some settings a battery of assesment instruments may be routinely administered. That meeting may conclude with a referral elsewhere based on a decision that the client’s needs are not a fit for the agency services. Or, the client may be given an appointment for a first session of psychotherapy or be place on the agency’s wait- list. This intake process may take from one to several hours.
• The client arrives for a first session (or perhaps not, since a significant percentage of those given a first appointment do not arrive).
  By contrast, here is how the process works at an agency that offers a walk-in option:
  

The client decides to talk to a mental-health professional;

• The client arrives at the walk-in service and is asked to complete brief one- to-two page intake form;
• The session begins, usually less than an hour after arrival.
  If you were a client, which of the above processes would you prefer? If you were an administrator of a mental-health service, would you be asking yourself about the comparative cost of these two forms of service delivery as well as the accessibility of your services and satisfaction of your clients? What if you learned that one session is the modal length of psychotherapy and that most single-session clients report high satisfaction and significant improvement? Would you then begin to consider walk-in services as one element of your agency’s offerings?
  Elsewhere in this volume, you will find descriptions of a variety of different implementations of walk-in services. Some operate every day and some as infrequently as one half-day per week. Some charge a fee and some do not. Walk-in services do not screen; the client decides whether or not to come. (The exception to this is that agencies do not all serve the same client populations; e.g.some focus only on children and their families.) Several psychotherapy models can be adapted to the walk-in format. Central to the walk-in concept is the therapist’s firmly held belief that the walk-in session may be the only session. The focus of the session, therefore, is on what the client most wants to achieve at that particular time.
  The majority of walk-in clients decide that one session is enough for the time being. It is possible that clients may return at some point in the future for a subsequent walk-in session though they may not see the same therapist. Some walk-in sessions end with a referral for ongoing by-appointment counseling or other mental-health services.

Our approach aims to have a complete therapy occur in a single therapeutic encounter: no pre-session screenings or assessments, no earlier triage, and no follow-up built in to the process. By walk-in we are referring to an experience where the client walks into the clinic without an appointment, is seen by a therapist as soon as possible, and receives a complete single-session of therapy, at that moment. We have not built in routine follow-up, whether in person or by phone, in this model. Briefly, the model that plans to have a second contact (even if it is called a follow- up) is different than our mindset that the present encounter may be the only one the therapist and client may have. Of course we follow-up in exceptional cases such as when harm to the client or others is possible.

Walking in and expecting an immediate service has become commonplace. Our clients are used to it. They walk in to hairstylists, to restaurants, to income tax services, and drive in for a coffee or banking. Twenty-five years ago in Calgary, Canada, we watched as walk-in medical services became more and more popular. If anything, mental-health professionals have been behind the times, but there are signs that we are catching up.

We (AS and MB) have been developing and providing walk-in services at locations in Canada, the United States, and Mexico (Bobele, et al., 2008; Slive, et al., 1995; Slive & Bobele, 2012; Slive, Bobele, McElheran, Platt, & Rodriguez, 2014). Such services are developing in countries around the globe, none more so than in Canada. We strongly believe that walk-in services have found a place in the continuum of mental-health services. In this paper, we provide food for thought for those who are in a position of wanting to advocate for walk-in services to your constituents and funders. We will focus on three specific reasons:

1. They seize the moment.
2. They work.
3. They are efficient.

But First, a Case Example

Recently, at the Community Counseling Service (CCS) operated by Our Lady of the Lake University (OLLUSA) in San Antonio, Texas, Maria, who was in her 50s walked in without an appointment with her 21-year-old daughter, Antonia. They were given a brief intake form to complete, and the session began about 20 minutes later. Maria and Antonia had heard about the walk-in service from their primary-care doctor after Maria told the doctor that she was having difficulty coping. She was sleeping more than usual, feeling sad and tearful, and regularly missing work. Antonia pointed out that she had come to the session to support her mother. Both Maria and Antonia attributed their difficulties to the fact that Victor, Maria’s husband and Antonia’s father, had died three months earlier after a long illness. Maria told us that she wanted to “feel well enough” to get back to work on a regular basis. Friends and family had been advising Maria that she was spending too much time dwelling on the loss of her husband, that she should forget him. However, Maria found that she was unable to stop thinking about him. She even found that in her “conversations” with Victor since his death, he had been advising her to “move on.”

Following a 10-minute break in the session (some walk-in services operate with a team of therapists that are available to consult during the session) the co-therapists reflected to Maria that her well-intended attempts to forget and move on were not working. If anything, those efforts seemed to lead to more remembering. So, the therapists suggested that Maria consider “forgetting about forgetting.” Surprisingly, Maria immediately agreed.

For the remainder of the session the therapists, Johanna Becho and Karla Caballero, borrowed from the work of Michael White (1988), who demonstrated that saying “hullo” can sometimes be a more effective grieving strategy than saying goodbye. The therapists encouraged Maria and Antonia to share their memories of Victor with each other. Antonia made two lists on a whiteboard in the therapy room. One list (about 15 items) described the characteristics of Victor that they most wanted to hold on to (e.g., his romantic nature). The other list (4 items) consisted of his qualities that they preferred to stay in the background (e.g., his quick temper). The therapists took photographs of each list and gave copies to them. The mother and daughter were advised to keep the list of more positive qualities with them at all times so they could refer to it whenever they needed to remember Victor. As far as the less desirable listing, they were instructed to store it somewhere in their home so that it was not always present but could be retrieved “should it be needed.” At the end of the session, Maria was smiling, more energetic and making plans with Antonia for the remainder of the week. She thanked the therapists for encouraging her to remember Victor, and to not forget him too quickly. They were invited to walk-in again, if they needed. At the time of this writing, they had not returned.
Now, we return to the three reasons.

They Seize the Moment