The Beginning Of Therapy & First Sessions

Written By Canh Tran

Why First Sessions Are Important

  • Instills hope in the client for change (or hopelessness for change)

  • Impacts the client’s relationship and perception of therapy and future help seeking behavior

Core Themes To Consider With First Sessions

  • Rapport building

  • Setting expectations and ground rules

  • Assessment

  • Evaluation

  • Mental status exam

  • History gathering

  • Questions and answers

  • Narratives and stories

  • Asking for feedback

  • And more

What Happens During The Beginning of Therapy?

  • Commitment and agreement between patient and clinician (boundaries, the frame, attendance, cancellations, sick policy, etc.)

  • Education client about treatment and therapy (risks and benefits, what to expect, etc.)

  • Orient client to therapy (what to expect, what therapy is, what therapy is not, the role of the therapist, role of client, etc.)

  • Elicit potential barriers to therapy (unintended consequences, money, time, commuting, etc.)

  • Answering questions and concerns client may have

  • Informed consent

  • Discussing when to terminate/end therapy

  • And more

Things To Try Out In A First Session

  • Establish the therapeutic alliance and build rapport

  • Introductions

  • Let clients know about how you structure a first session

  • Discuss how you work and your therapeutic approach

  • Inquire about previous experience in therapy

  • Normalize feelings of anxiety if first time in therapy

  • Validating the client

  • Inquire if they have any questions or concerns before starting

  • Inquire about client’s history, family, formative life experiences

  • Inquire about living situation

  • Inquire about support system

  • Inquire about family history of mental health issues

  • Inquire about suicidal ideation, homicidal ideation, self harm

  • Inquire about client’s best hopes and goals for therapy

  • Inquire about how client have managed their problems so far

  • Assess for strengths

  • Assess for barriers and challenges

  • Summarizing what the client said

  • Paraphrasing what the client said

  • Clarifying what the client said

  • Informed consent such as limits to confidentiality, treatment plan, diagnosis

  • End with a preliminary verbal treatment plan on observations made so far

  • Inquire if they have questions or concerns before ending session

  • Let clients know how to contact you outside of session and boundaries around outside contact

  • And more

Statements And Questions You Can Try Out

  • What are your best hopes from therapy?

  • What are your expectations from me?

  • What’s getting in the way of what you want?

  • How would you know when it’s time for us to end therapy?

  • Miracle question: If you had magic powers and woke up tomorrow, what would you magically fix/solve/get rid of?

  • Do you have any questions for me that would help you feel more at ease?

  • What helps you feel more comfortable when meeting a new therapist?

  • Would you like me to lead the conversation today or do you have things you want to bring up first?

  • What’s been your experience working with someone who looks like me?

Remember

  • We are trained and experienced, but the client is the expert of their lives and have choice and agency to do what they’d like

    • This means they can end session/treatment with us at any time

    • We know theories, but clients do not fit neatly into a theory/box/category

  • Change is hard, challenging, and difficult

    • Ambivalence is normal and to be expected

    • Most clients, though not all, come into session with conflicts

    • Address ambivalence and apprehension early on

  • Relapse is normal and part of the healing process

    • Normalize this

  • Normalize and validate the client moreso during the first part/beginning of treatment

  • We hold hope for clients even when they are hopeless

  • Collaborative and work with clients (therapy is a two-way street)

  • Ask for feedback and respond accordingly

  • Display empathy, warmth, and compassion

  • Hold flexible, yet firm boundaries based on your own personal and professional boundaries

  • And more

Goal of an Effective and Useful First Session

  • Helps reduced drop out

  • Increases hope

  • Increased motivation to achieve goals

  • Client is educated and aware of process and treatment of therapy

  • Helps set expectations, agreements, etc.

  • Helps with client ambivalence and uncertainty

  • Provides them with a roadmap of what to expect vs. being overwhelmed and confused

  • Provides client notice/awareness that there will be an ending to therapy eventually

  • And more

Questions To Reflect On

  1. What is my goal/are my goals for a client during a first session?

  2. What’s the most necessary information/data I need to gather in the first session?

  3. How can I instill hope for change and growth during the first session?

  4. What are the challenges/barrier for me personally as a therapist during the first session?

  5. As a client in therapy personally, how do I/would I want to feel and what do I want to get out of a first session? How have I felt before, during, and after my first therapy session?

  6. How do I want clients to feel after their first session?

  7. How do I want to structure my first sessions? More formal? Informal?

Canh Tran
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