Single-Session Counselling in Mental Health Services: Evaluation of a New Program

Organizations offering mental health services are in need of innovative solutions to address a lack of accessibility and availability in service provision. Waitlists for counselling services are long, often forcing those experiencing mental health difficulties to rely on acute care services in the interim. One option, single-session counselling, allows consumers to access services when they need it, as often as they need it. This service model can be integrated into current services to contend with difficulties related to efficiency and accessibility. The current study evaluated a new single-session counselling program offered in an outpatient community mental health clinic in Northwestern Ontario. The majority of participants rated the service favourably, and experienced a decrease in mental health difficulties and associated impairment. Single-session counselling reduced difficulties associated with the presenting problem, and allowed access to services sooner. Continued implementation of this model of care is supported by the current findings. Dissemination of information describing the nature of single-session counselling, as well as outcomes of program evaluations such as the current study, may help to increase acceptance of its integration into ongoing mental health services. SINGLE-SESSION COUNSELLING 5 Single-Session Counselling in Mental Health Services: Evaluation of a New Program Mental health service providers across Canada are facing an ever-growing client base, with insufficient resources to manage the increasing demand. Seventeen percent of Canadians report a need for mental health care in the past year, with 36% stating that a need for counselling services was only partially met or unmet (Sunderland & Findlay, 2013). Mental health service agencies in Canada have reported wait times of up to two years for counselling, with upwards of 900 individuals waiting, and even temporary closures of intake services due to an inability to meet demands (Mireau & Inch, 2009; Stalker, Horton, & Cait, 2012; Young, Dick, Herring, & Lee, 2008). When clients first seek counselling, motivation and need are at their highest, particularly for clients presenting in crisis (Bloom, 2001; Brown, Parker, & Godding, 2002). As clients remain on the waitlist to receive services, they become increasingly dissatisfied and lose motivation, resulting in high rates of nonattendance for first appointments (Sherman, Barnum, Nyberg, & Buhman-Wiggs, 2008; Stalker et al., 2012; Taylor, Wright, & Cole, 2010). Missed appointments and drop outs resulting from lengthy wait times further decrease accessibility and efficiency in the provision of services. Identifying accurate statistics on mental health care in Northwestern Ontario is problematic, as methods used to obtain data on utilization and waitlists for medical care are not validated across mental health services, and the information gathered is excluded from reports due to a lack of confidence (North West Local Health Integration Network [NW LHIN], 2013). One of the recommendations made for Ontario's Mental Health and Addictions Strategy was to monitor wait times for community-based mental health and addiction services, highlighting the SINGLE-SESSION COUNSELLING 6 need for reliable waitlist data in these areas (Ministry of Health and Long-Term Care, 2010). Policy makers in Northwestern Ontario have relied on general opinion surveys to understand current issues. In 2009, the Mental Health and Addictions Survey asked respondents to identify ways to improve the design of mental health services in the region. Information on the perception of mental health services was obtained from consumers, their families, and service providers (NW LHIN, 2010). Responses focused on reducing barriers to accessing services, shorter waitlists for services, and making the system easier to navigate by having a single point of contact that can help consumers indentify and access appropriate services. The "Shape Your Care, Share Your Story" community engagement initiative also addressed perceptions of the regional health care system, seeking contributions from residents of the LHIN and health care professionals (Centre for Rural and Northern Health Research, 2009). Accessibility and availability were again highlighted as issues. Residents and health care professionals expressed a lack of awareness of mental health services, as well as gaps in the services provided, and a lack of integration (Centre for Rural and Northern Health Research, 2009). Services in the NW LHIN are described as having "absurdly long wait times," and health care professionals emphasise that significantly delayed access to care for those with mental illness puts these individuals at an increased risk (Centre for Rural and Northern Health Research, 2009). Community Mental Health Services at St. Joseph’s Care Group in Thunder Bay reviewed the issues currently faced in the provision of services in a Health System Improvement PreProposal submitted to the NW LHIN (M. A. Mountain, personal communication, January 14, 2015). The waitlist for individual counselling was over 200 people at the end of November 2014, and had been steadily increasing from 137 individuals in November 2013. Maximum wait times SINGLE-SESSION COUNSELLING 7 during this time period were anywhere from approximately 4 months to 19 months depending on the symptoms presentation and associated level of priority. Those waiting for counselling were described as the most complex and vulnerable of the outpatient group. The pre-proposal also stated that individuals who seek counselling experience increased psychosocial difficulties while not receiving services, and often depend on emergency medical services to meet their needs (M. A. Mountain, personal communication, January 14, 2015). Data from the acute sector provides further evidence of an inability to meet demands for mental health services in Northwestern Ontario. The number of individuals accessing the emergency department for mental health reasons in 2011-2012 in the NW LHIN was almost twice that for Ontario as a whole, and 4 times the provincial rate for individuals presenting with substance-related difficulties. The Thunder Bay District has the highest rate of emergency department visits for those with mental health conditions per 100,000 in NW LHIN. High rates of acute care utilization demonstrate a need for more immediately accessible services (NW LHIN, 2013). Many mental health service providers and consumers in Northwestern Ontario contend with unavailable, inaccessible, and inefficient services (NW LHIN, 2010). Due to these issues, individuals seeking mental health care are forced to cope without treatment for an indeterminate period of time, or rely on emergency medical services (NW LHIN, 2013). This is evident in the length of waitlists for services, and the data on acute care utilization by individuals presenting with mental health and addiction concerns (NW LHIN, 2013). When treatment becomes available, drop-outs and missed appointments are common, further contributing to service inefficiency and inaccessibility (Stalker et al., 2012; Taylor et al., 2010). Local mental health service providers and consumers identify accessibility as an area requiring attention in mental SINGLE-SESSION COUNSELLING 8 health care, and strategies for increasing accessibility are currently being considered in the provision of ongoing mental health services (NW LHIN 2010). Single-Session Counselling Single-session counselling is broadly defined as any therapeutic encounter determined at the onset to be self-contained by both the therapist and the client (Slive & Bobele, 2012). The session is approached as a single encounter, regardless of the client's intention to access the service in the future. This is to be distinguished from a client terminating or dropping out of traditional counselling after one session, as traditional counselling is conducted under different assumptions, and termination may result from factors other than treatment sufficiency (Hymmen, Stalker, & Cait, 2013). Research into effective psychotherapy duration traditionally suggested a linear relationship between number of counselling sessions and treatment outcomes, where longer durations of counselling result in greater improvements (Howard, Kopta, Krause, & Orlinsky, 1986). Recent research, however, demonstrates that while longer durations of counselling are more effective over all, rapid improvement occurs early in treatment, with each additional session producing less significant results, and the rate of change varying from client to client (Baldwin, Berkeljon, Atkins, Olsen, & Nielsen, 2009; Stulz, Lutz, Kopta, Minami, & Saunders, 2013). In fact, if counselling clients have not experienced functional changes by the 8 th session, the likelihood of significant change is greatly diminished (Baldwin et al., 2009). This shift in the understanding of required length of treatment, along with increased demand for services and decreased resources, resulted in a movement towards more brief models of counselling, and the implementation of single-session counselling (Hymmen et al., 2013). SINGLE-SESSION COUNSELLING 9 In Ontario, single-session counselling has primarily taken on the form of walk-in counselling programs, providing immediate access to services (Hymmen et al., 2013). Programs that schedule an appointment for single-session counselling for the same day or up to a couple weeks in advance also exist, primarily outside of Ontario (Hymmen et al., 2013). For example, the Access and Early Intervention Program in Red Deer, Alberta adopted pre-scheduled counselling sessions in the provision of intake assessments for community mental health services (Taylor et al., 2010). With most single-session counselling programs, the option to return for future sessions is presented to clients, although this is not considered a "pure" form of singlesession counselling, which is, b