First psychotherapy sessions. How I love them!
I love the energy, getting a feeling of each other,the fact that there is not much preparation to be done, and little expectation for anything to be “fixed” in a first session. Maybe I love first sessions because I suffer from incurable curiosity! When I look at my diary and I see a new name there, I always find myself intrigued: How old is this person – are they a child, teen or an adult? Are they coming alone, or with someone? Will I know it is he or she when I take a glance around a full waiting room? And most importantly: was it them or possibly their family that prompted them to take the big step to book an appointment with a psychologist?
Because IT IS a big step to make that call and book a first appointment. After all, you will walk into the office of a stranger, open your deepest heart and share intimate details of your life! How does one, as a client, explain a problem, plus give some background info, in less than an hour? This alone is intimidating enough to stop people making that first phone call.
This is also the challenge for the clinician in “the other chair”. A first session is a delicate dance between getting information and building rapport (in other words: creating a sense of connection or a feeling of being on the same team). A big task! My colleague Oliver and I often lament the way minutes fly in a first session. How wonderful it would be to have a faulty slow-ticking clock to stretch the 51 minutes to something more substantial. Indeed, when I do my notes on my “first session template” I often find myself with glaring gaps under numerous headings. “Medical history” – I didn’t ask. “Substance use” – need to get back to this. “Family structure” – find out more. The only thing that comforts me when I start feeling guilty about the gaps, is knowing that 51 minutes are indeed short. That if something is important, it will come up again. That there will be more time to flesh things out. The most important thing is not to stick to a form with numerous headings, but to stay with what the client is bringing to the table.
Therefore, one topic that is never left out is the question of the “presenting complaint”. The problem. The thing that brought the person here. Yes – the referring GP often sends a referral with some diagnostics and maybe a K10 or DASS score (these are short screening tests to assess for depression, anxiety, and general stress). But the truth is that I rarely look at this before I spend my first hour with the client. Often the reason is that the letter comes in with the client in the first session, and I don’t want to spend precious minutes reading a letter I can also read afterwards. But more compellingly, I prefer to meet new clients “where they are at”. Not where their diagnosis is at. Not where the recommended therapy intervention is at. Not where their K10 score is at. But where THEY are at. This I find is often best done without a detailed reading of the referral letter (other clinicians might differ from me on this!).
Another question that I rarely leave out is “the client’s goals for therapy”. In other words: what does the client want help with? When someone has difficulty formulating this, I might ask: If we were to jump ahead a year to May 2021, and you were to say “things are better”, what would have changed from now to then? The client’s answer paves the way for good therapy to happen. For example, if their goal is A, but I want B for them, then I am not meeting them where they are at. I need to work with them towards A (not B, if B is vastly different from A!).
Sometimes I do deviate from this a little bit though. If we re-visit these goals after a few sessions when feel I have come to know the person, I often add my “cheeky wish list” for what I would want to add to the future picture. The client’s goal, for example, may be to have “less anxiety”. My cheeky addition would be something like “I’d love to see you experience the joy of deepened relationships” or “How wonderful it would be to feel a deeper sense of contentment with where you’re at, even if it is not perfect”.
One more thing a client can expect in a first session is a short chat on confidentiality. I must admit that I often forget this, and always feel I can kick myself afterwards as this is so important. The psychologist should explain that everything that is said is confidential, except in the case of risk: risk to self or to others. I usually do it in a rather blunt way by saying “If you tell me you are going to hurt or kill yourself, or anyone else, it would be highly irresponsible of me to keep that to myself, jot it down in your notes, bid you goodbye and hope for the best!” By stating this explicitly, expectations are managed in a clear way.
While writing this blog, I suddenly remembered a book I studied ages ago as part of my Masters. Lo and behold, after some searching, I found it (rather dusty, admittedly!) in my bookshelf. It is called “The First Interview”.
Looking at the front page I was fairly critical of Mr Morrison’s graphic designer’s choice: white background, sharpened pencil (mine always seem to be blunt!), a feeling of being in control, writing things down, an efficient clinical approach with little colour and creativity.
How would I decorate it? I would use a myriad of photos, slices of the client’s life, sounds, voices and stories came to my mind as I was happily re-designing the cover in my imagination. Then it dawned upon me. I was too rash in my judgement. The current cover is actually not too bad after all! Look – it is a pencil, not a pen. Look – there’s an eraser at the back of the pencil. Information is taken, but it is fluid and changeable. The background is a white page! How wonderful, a real blank slate (in line with my previous thoughts about not getting too caught up in referral letters and K10 scores). There is space to be filled with all the “slices of life” and stories. Though I’m still not over the moon with the “Revised for the DSM-IV”. As we are now already on the 5th Version of the ever-evolving Diagnostic and Statistical Manual of Mental Disorders. Moreover, I am not a lover of diagnoses unless they are helpful – which is not too often in my opinion!)
The author of “The First Interview” is an optimistic man, it seems, when you look at the 317 pages in the book. There is a lot to do in a first session. A lot of information taking, a lot of assessment and a lot of rapport building. I will add something else: a first session should also be therapeutic. The hard dividing line between “Assessment” (Session 1-2) and “Therapy” (further sessions) may become a bit blurry. After all, this is what the dictionary tells me about the meaning of the word ‘therapy’: a treatment that helps someone feel better, grow stronger.
Yes, most of the “therapy” will happen in later sessions. But if there is a slight sense of feeling better, a slight growing stronger in Session 1 already, it sets the scene for more to come. When this “therapy” happens together with the information taking, the explaining of confidentiality and the building of rapport, you have a recipe for a really good first session… given that you always meet the client where they are at.
Now… let me go sharpen those pencils!
Felix & Sage Psychology