Session 1: Setting the Structure

The first session is sets the tone for therapy.  However, clients come in with their own expectations, barriers and understanding (or lack) of the process.  It's up to the practitioner to ensure the client understands what's happening.  With that said, so many early career practitioners struggle with how to manage the first session.  I hope this information below helps.

a.What does engagement mean?

• Therapeutic alliance, positive regard, empathy – Carl Rogers
• Rapport building
• Connecting 
• Client actively participating in the treatment process 
• Client and therapist defining the problems, setting goals and implementing interventions to meet those goals

1. Why is engagement important?

Research in varied clinical areas consistently demonstrate the main factor correlated to influencing treatment outcomes is therapeutic alliance (otherwise known as engagement).

Factors impacting general client improvement:

• Therapist common factors (empathy, warmth, safety etc) 30%
• Therapist technique (unique to specific therapies, therapist directiveness) 15%
• Placebo (client expectation) 15% 

c.What are the Micro skills that make up engagement?

A critical element of the first point of contact with a client is to engage them in the therapy process.  

Initially, how do you do this? 

• Small talk – did you get here OK? Did you find the place OK? Comments about the weather?
• Acknowledgement of their effort/commitment to attend.
• Body language – open, smiling, pacing

What are the micro-skills?

• Positive regard – the clients are doing the best they can
• Recognizing and emphasise client strengths
• Genuine, Warmth and openness
• Empathy to understand the client as though in their shoes
• Flexibility
• Self-knowledge and maturity and confidence
• Competency
• Commitment
• Humility
• Instilling hope
• Elicit treatment goals
• Agree collaboratively on addressing these
• Arrange convenient meeting times
• Honour cultural values and context

1. Why do clients drop-out of therapy?

• Client variables – cost, other commitments, stage of change (pre-contemplator/contemplator), not feeling comfortable with the therapist, not feeling heard/valued/understood by the therapist, unrealistic expectations of therapy, not clear about their goals.
• Therapist variables – poor skills at engaging, not listening, not being clear about how you can help , driving therapy towards “your goals” not “client goals”, lack of skill in clinical interventions.
• Organizational variables  - opening hours, cost

1. What is alignment?

Alignment is working together on the client’s issues and goals, not yours.

1. What are the signs/indicators of not being aligned? 

• Client not completing homework
• Client not participating “enough” in the session – feeling like you are doing more of the work
• Non-verbal cues of non-commitment 
• “but….”
• An absence of “I was thinking, I realized, I practiced”
• No improvement
• Therapist feeling frustrated
• Pattern of cancellations

1. Questions to ask clients when there are alignment issues? 

• What has been most helpful in our sessions so far?
• What have I done or said that has been most helpful?
• What has been least helpful in our sessions so far?
• What have I done or said that has been least helpful?
• What do we need to do in the future to make these sessions more helpful or productive?

Note: Important to take the “one down” position by asking these questions in a neutral and curious manner, to be non-critical and non-judgemental.  Be sure to be ready to face what they say, and not take it personally.  It is an opportunity to return being aligned. 

Psychology is not just the study of pathology, weakness, and damage; it is also the study of strength and virtue.  Treatment is not just fixing what is broken; it is nurturing what is best.

1. What goes on for clients in the 1st session?

• They feel helpless
• They are highly anxious, particularly in the first 10 minutes
• They are unsure what to expect from counselling or how it works
• They are not sure what to talk about
• They are unsure how long the process will take
• They are desperate to know whether their problem is normal and whether the therapist thinks it can be resolved

1. What can the therapist do in the 1st session to help engage the client?

• Remain present with the client
• Listen, reflect, and listen some more to the client
• Demonstrate a willingness to work with the client on understanding and resolving their issues
• Limit note taking – it takes you “away” from being connected
• Use open-ended questions “tell me what it is like for you with respect to X issue”, “help me understand ….”, “I am interested in understanding X more clearly, please can you tell me more about that”
• Facilitate the client telling their story – “you mentioned earlier about x, can you tell me more about that…”
• Use probes to help the client gain clarity of why they have come to therapy – “is that something you are wanting to address in therapy?” 
• Keep the client’s agenda in focus
• Where appropriate, communicate an appreciation of how difficult it may have been for the client to attend the first appointment – “given you have not spoken about these difficulties to people… or…given it is important for you to be in control… I imagine it may have been tough for you to make it here today”.
• Be receptive to changes or emotional distress in the client during the session
• Establish interactive dialogue or “turn taking” rather than either party dominating the session
• Not needing to be the “expert” on the client, you are the “expert” on the process 
• Establish a clear therapeutic boundary and framework
• Understand your own presence in the room, your nonverbal behaviour, and how you may be seen by the client
• Regulate and make room for issues and feelings that are activated by the client’s story or their presentation
• Summarise using the client’s language 

1. Why is structure important?

In the context of:

• Client being distressed
• Client not aware of “the process” or what to expect
• Client feeling overwhelmed and helpless

Structure in the first therapy session allows for:

• Direction – “the first session is really about me gaining an understanding of what has brought you here today, and establishing some goals for the work you might want to do in therapy” 
• Containment – “holding the vessel of the client’s distress”
• Setting boundaries (time, what the session will look like, what the content can include)
• Helps deal with “disruptions” in later sessions  
• Providing the client with an experience of therapist confidence/competence

1. What to include at the start of 1st session?  

• Confidentiality, and the limits of (risk of harm to self or others, subpoenaed, criminal offences, informed consent).  Code of Ethics: “Psychologists inform clients at the outset of the professional relationship, and as regularly thereafter as is reasonably necessary of the limits to confidentiality”.
• Length of session
• Fees and cancellation policy
• Funding source – meaning of (including session numbers and reporting requirements)

• Framework of approach eg, “Today’s session is about me gaining an understanding of what has brought you here today, and establishing some goals for the work you might want to do in therapy” and “usually, the session structure looks like….”

1. How to close the 1st session?

The aim of closing the 1st session is to communicate to the client that they have been heard, to establish goals in therapy (that can be refined and developed future in later session) and that therapy can offer a way for them to explore and work on their presenting issues.

• Summarise the main issues discussed using the client’s language and clarify that you have understood correctly
• Elicit goals for therapy (specific, concrete and measurable) – “If you were to continue coming to see me, what would you want to get out of this” or “What would you like to see changed for yourself, and how are we going to know when we have achieved this?”
• Be clear about how you can help and areas that you can’t help with “Yes, I can help you with goals X, Y and Z but I do not feel specifically equipped to help with goals A”.  
• Elicit commitment for future sessions “would you like to return to see me to begin working towards these goals”.  Encourage the client to make repeat bookings to ensure they get the appointment time they want.
• Agree on frequency of sessions.
• Educate client regarding the process of therapy – “often takes time to resolve issues, it is a process of self learning and developing new strategies, and is a collaborative working partnership”, “sometimes problems can get worse before they get better, just like a physical illness eg flu or open cut wound”
• Inform the client of your availability and contact details
• Normalise possible distress after session – encourage client to use adaptive coping strategies.

Health care industry standards – active vs discharged health model

• Active vs discharged cases – “discharge back” to GP care.  If a GP has referred their patient to you for specialised treatment, you need to advise them accordingly.
• Shared-care between other professionals also involved in the client’s care.  
• Psychology is a specialist (like cardiologist, gynaecologist) – you NEED to respond consistent with the medical profession.

Strategies for excellent client care 

• Call referring GP after initial session and at review times – shared care, building working relationship, marketing self and business, increasing credibility
• Know the process – getting through the reception  - “I am a psychologist and was referred one of Dr’s patient x.  I was phoning to introduce myself and discuss patient”.  “Is there a best time to speak with Dr?  Can I leave a message please”.  
• Script for GP:  “My name is x, Psychologist working for [Practice name].  Calling to speak with you about client x who you referred to me.  As I have never spoken with you, I thought this would be a useful opportunity to introduce myself.  Did you receive my letter….was the information in this useful, do you have a preference on content?  As I said in letter…x has diagnosis of x, main issues at present are x, planning to help them with x.  Medically or psychologically, is there anything else you think I need to know about your patient?”
• Letter to GP after session 1
• Letter to GP after session 6 and 10 (or whatever is relevant at the time)
• Letter to GP upon discharge or termination from therapy
• Responding timely to calls/requests for letters
• Following up – consistent, timely, reliable, - portrays message “I Care” 
• Professionalism – be on time, no client information in sight, not answering calls during sessions, not talking about clients to others, limited self disclosure

Dealing with cancellations

Practice policy – [What is it that incurs full fee]

• Rationale for charging Cancellation fee – your time, respect to your time, commitment to therapy, reducing cancellation rates, consistency with appointments to allow for discharge

• Barriers to charging – anxiety about damaging the therapeutic relationship, worry client can’t pay, worry that client won’t return because of the cost, minimizing the impact on your time

Active Client Follow up

Don't be afraid to contact the client if they don't return to therapy. This effort will help the client understand that you are actually there for them and are invested in their journey.