Tag Archives: First Therapy Session

Instilling Hope in a First Session

I’m starting a new placement next month, and I want to know how to be as helpful as possible in my client sessions. How can I handle the first session so they are likely to want to come back and continue therapy?

Starting your first placement is a big step and one that most clinicians approach with some amount of anxiety as well as excitement. It’s a good idea to start by thinking about the first session with clients and how to engage them from the beginning. There is a lot to do in a first session–getting informed consent, establishing a therapeutic alliance, following the client’s story, beginning an assessment, and responding to the client’s wishes and goals–and chapter 3 of my book covers this topic. Communicating empathy and understanding is crucial in the first session as clients share their distress and pain. They are motivated to continue therapy when they have a feeling of hope in the therapeutic process. In this blog, I will describe two ways to instill hope during the first session.

First, clients feel hopeful when they have an awareness of their strengths, which provides confidence that they can face and overcome their difficulties. It is important to hold a “both/and” perspective in talking about strengths, reflecting that you understand the seriousness of the clients’ concerns and problems while also pointing out the capabilities reflected in their life stories. Most often, clients enter therapy feeling discouraged and self-critical. Feelings of shame and fear are common, whether their symptoms are new, have occurred at other times, or have been ongoing. There are a number of ways to identify and highlight the client’s strengths, depending on the initial presentation and the flow of the session. When the client leads with a description of what isn’t working and how their life has been impacted negatively, you can ask how they have coped with this difficult situation and support whatever positive coping strategies they report using. An example is “It’s impressive that you’ve been able to connect with a friend at least once a week, even though your depression has interfered with your appetite and sleep and your mood has been very low.” You can also ask about different areas of the client’s life and contrast areas of success with areas that are more problematic by saying, for example, “It sounds like your anxiety has made it hard to speak up in meetings at work, but you were able to advocate for your daughter to get the help she needed at school.” It also helps to reflect the client’s statements of strength in addition to reflecting and empathizing with their problems.

Second, clients need to leave a first session with a sense of hope in and direction for the therapy. I use the last 5-10 minutes of the first session for this purpose, including asking the client how it has been to talk about her concerns, summarizing how I would anticipate working together on her presenting issues, and expressing confidence that therapy can be helpful. I emphasize the collaborative nature of therapy by using terms like “working together” or “what we might look at,” and I provide a realistic assessment of the uncertainty and difficulty of changing longstanding patterns along with my belief that things can improve. A short summary statement is “If you want to continue working together, I would recommend looking at the emotions that have led to your outbursts of anger and how you can develop different ways to express those emotions before they become really intense. I know you’ve avoided the fear and sadness we talked about very briefly today, but I believe those emotions are related to the anger outbursts. You said your goal is to reduce your anger, and if you’re willing to look at those other emotions as you’re ready, I think you’ll be able to do that.”

If you keep these two strategies in mind in your first session with clients, I believe you’ll help them feel hopeful about continuing to work with you in therapy. If you’re interested in reading more about this and related issues, click here to order from Amazon or here to order from Routledge.

Assessing a Confusing Initial Presentation

Diane SuffridgeI just had the first session with a 22-year-old client at my practicum site. She seems depressed, but there is also something different about her than my other depressed clients. I found it hard to connect with her, which is unusual for me, and she couldn’t really tell me anything about her history. She says her childhood was fine, but she doesn’t remember much until she was about 11. How can I figure out what is going on for her?

You have identified several factors in your client’s initial presentation that leave you feeling uncertain about your diagnosis and conceptualization of her difficulties. An important first step in understanding your client is to acknowledge the confusion you feel rather than rushing to a premature conclusion. It may take several sessions to begin to piece together a cohesive picture, but it is preferable to move slowly than to attempt to resolve your questions too quickly. I’ll outline some approaches I would recommend for the next 3-4 sessions to move toward understanding your client more fully.

It seems likely that this client will benefit from your direct expressions of empathy and understanding. This is the basis of all therapeutic relationships, but your experience that it was hard to connect with her suggests that she has more fear and expectation of harm or rejection than many of your other clients. This may be outside of her awareness, so she probably didn’t say anything directly to reflect fear or mistrust. However, pay particular attention to making reflective statements, summarizing what you understand, and validating her decision to seek help for her distress. This will create a therapeutic atmosphere in which she will gradually develop trust and will be more open in talking about herself.

Since you have identified differences between this client’s presentation and others who describe their problems in a similar way, I would also recommend asking clarifying questions in order to avoid making assumptions about the meaning of her statements. For example, when she says she is depressed, you could say “people experience depression differently—how does it affect you?” or “can you tell me more about what is happening with the depression?” Since aspects of her presentation indicate the possibility of early trauma, I would also recommend reviewing the diagnostic criteria for PTSD and dissociative disorders so you are familiar with symptoms that could be interpreted as depression but are actually the result of trauma. A way to begin to identify dissociation would be to ask something like “would you describe yourself as more sad or more numb?”

As your client feels more comfortable with you, she may begin disclosing unusual symptoms and experiences that go beyond depression. This is another reason to familiarize yourself with other diagnoses, including dissociative and psychotic disorders, that could present similarly to depression. You may want to ask direct questions about these symptoms in order to identify an accurate diagnosis, and it is best to do this in a straightforward, normalizing manner. Examples are “Some people find themselves hearing voices when no one is around. Does this ever happen for you?” or “Sometimes people feel detached from their surroundings or themselves, as though they’re looking at themselves from the outside. Have you ever had that experience?”

Last, I recommend continuing to be aware of your observations and emotional responses to this client. Since she seems to hold large parts of her experience outside of awareness, the nonverbal communication between the two of you will be central in your understanding of her. Including this information in your assessment will lead you to a more accurate diagnosis and case formulation. It is also likely that you will continue to have some questions for the next several months, so continue move slowly in reaching conclusions. Identify what things seem clear and what things are uncertain about her presentation, and hold the ongoing ambiguity.

I hope you find this helpful in assessing clients who have a confusing or puzzling presentation. Please email me with comments, questions, or suggestions for future blog topics.