Single-Session Therapy and the Therapist’s Fear of Opening Up a Can of Worms₁

by Windy Dryden PhD

Many therapists in the Single-Session Therapy (SST) community consider that its practice is best informed by a set of beliefs collectively referred to as the single-session therapy mindset (Cannistrà, 2022) or single-session thinking (Hoyt et al., 2021). When therapists first encounter SST, they will likely bring to bear what I have called the conventional therapy mindset (Dryden, 2023a) when appraising SST. Many frequently asked questions (FAQs) that therapists pose about SST come from those with this latter mindset (Dryden, 2022). As such, when responding to these questions, it is vital to consider this difference in mindset.

One of the concerns that therapists have about SST is that it opens a can of worms for clients. The phrase can of worms seems to originate from the USA in the 1950s, where anglers would buy sealed metal cans of live worms for bait. When they opened a can, if they did not take care to close it, then the live worms would escape, and the fishermen’s attention would shift from catching fish to recapturing the live worms, and chaos would result. According to this scenario, opening a can of worms is not the problem. It is the fisherman’s lack of care to close the can before other worms can get out.

By using the opening up a can of worms analogy, the therapist, new to SST, fears that the SST practitioner would do the same as a careless angler: by asking the client to discuss a concern, they would not take care with the result that the client’s other problems would spill out and not be contained, with the consequence that the client would be harmed.

While I cannot say this would never happen in SST, several factors would reduce the chances of this happening.

Gain the Client’s Informed Consent

Single-session therapy, as with other forms of therapy delivery, is based on informed consent. Here, the client consents to work with the therapist on the understanding that the latter will help them achieve what they want by the end of the session with the knowledge that further help is available to them if needed. When the client knows and consents to the parameters of SST, this has a containing effect on them.

Orient the Client to Their Session Goal

Thus, the client is coming to therapy with the idea that they and the therapist will work together with their goal firmly in mind. If the client’s goal cannot be achieved, the therapist will be honest in telling them what they can and cannot help them with, leading to the setting of an achievable goal. The main point here is that the client’s achievable goal provides the focus for the work. Thus, the goal-oriented focus of the session provides additional therapeutic containment so that only one worm, i.e., client issue, is let out of the can.

Agree on a Therapeutic Focus

Whether the therapeutic focus is on the client’s issue or goal, the purpose of a focus is to provide an opportunity for the client to give their attention to one issue. If they have only one issue, then the can of worms phenomenon is irrelevant. Here, the client’s can contains only one worm. If the client has other issues, the focus is on one agreed issue. This focus helps the therapist and client deal with the issue in the knowledge that while the client may have other issues (other worms in the can), the therapeutic focus helps the client deal with one issue (worm) at a time. In doing so, the therapist keeps the lid on the can so that the other issues (worms) can be dealt with, perhaps later.

Seek the Client’s Permission to Be Interrupted

One of the critical skills employed by the SST therapist is interrupting the client when the client departs from the agreed focus. As I have mentioned elsewhere (Dryden, 2023a), the best way for the therapist to do this is to give the client a rationale for interrupting them, gain their permission to do so, and agree on the best way for them to do it, if necessary. As the primary purpose of interrupting the client is to maintain the agreed focus, doing so ensures that the issue remains the object of discussion. It helps the client to put back into the can other worms (issues) that may be struggling to escape.

Check In with the Client

It is also common practice for the SST therapist to check with the client periodically that the client is discussing what they want to discuss. Using our analogy, is the worm the one the angler (client) wishes to use as bait (concentrate on)? If so, then the two proceed with the agreed focus. If not, and there is time, the focus is shifted to a more relevant issue. If checking in is not done, there is the risk that the agreed therapeutic focus is incorrect, and the more relevant issue (worm) will weigh on the client’s now divided mind (another worm will seek to escape from the can). Thus, checking in allows the client to talk about what they want to discuss, reducing the situation where other issues (worms) compete for attention (escape from the can).

Manage the Client’s Distress

The fear of opening up a can of worms is related to the concern that the client may become so distressed that the therapist would not be able to help them contain it, so they leave the session in a very distressed state and experience harm as a result. If this happens, the therapist has failed to follow the above- mentioned guidelines. The skilled SST therapist can facilitate the client’s emotional engagement with their chosen issue while helping them to contain their emotions. A further appointment is strongly indicated if the client is flooded with emotions which cannot be contained.

Offer More Help If Needed

One of the problems with the term single-session therapy is that no matter how many times it is stressed to therapists new to SST that it does not mean a one-off session and that more help is available to the client if needed, the term is often taken literally to mean therapy that lasts for a single session. This is why I have described my work in this area under the term ONEplus Therapy (Dryden, 2023b). The fact that more help is available to the client and that both they and their therapist know this at the outset is in itself containing for the client who has several issues to deal with. Knowing this, the client does not feel pressured to mention all of their issues in one session and risk the escape of more worms than they can process.

In conclusion, the skilled single-session therapist is aware of the risk of the session opening up a can of worms for the client and guards against this happening by a) ensuring that the client understands and consents to the session, which is designed to help them achieve what they have come for; b) by being focused on the client’s nominated problem and goal for the session; c) maintaining this focus by interrupting the client and checking in with them to ensure that as the session unfolds they are still discussing what they want to discuss, and d) ensuring that the client knows both at the outset and the end of the session that they can have more help if needed.

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_{1 In my view, it is disrespectful to liken a client’s issues to ‘worms’. However, I will use the ‘can of worms’ analogy here because other therapists refer to it while expressing their fears about SST.} 

Windy Dryden is Emeritus Professor of Psychotherapeutic Studies at Goldsmiths University of London. His goal is to disseminate SST/ONEplus Therapy. His latest book is ONEplus Therapy: Helping People at the Point of Need.

References: 

Cannistrà, F. (2022). The single session therapy mindset: Fourteen principles gained through an analysis of the literature. International Journal of Brief Therapy and Family Science, 12 (1), 1–26.

Dryden, W. (2022). Single-session therapy: Responses to frequently asked questions. Routledge. Dryden, W. (2023a). ONEplus therapy: Help at the point of need. Onlinevents Publications.

Dryden, W. (2023b). What’s in a name? What to call therapy when a client may come once. Inside Out, 100, 12-14.

Hoyt, M.F., Young, J., & Rycroft, P (Eds). (2021). Single Session thinking and practice in global, cultural and familial contexts: Expanding applications. Routledge.