Tag Archives: First Therapy Session

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.