Author Archives: Psychotherapy Networker

The Art of the First Session

By Robert Taibbi


Q: I know that the first session with new clients is crucial, especially when doing brief therapy. How can I make the most of it?

A: Like it or not, many of us are brief therapists by default. Stats tell us that clients go to an average of five to eight therapy sessions, but most of them go only to one, making it essential that we hit the ground running.

We all know the essential tasks of the first session in any kind of therapy: building rapport and a sense of collaboration, assessing and diagnosing, and formulating and offering a preliminary treatment plan. The tasks in brief therapy aren’t different, but they’re done in less time–meaning that therapists need to get to work immediately, and there’s little leeway for mistakes.

I find it useful to think of the first session the way a family physician might when a client shows up with an ailment. Basically, there are four goals to meet: getting on the same page, changing the emotional climate, clarifying the link between problems and personality, and offering a clear treatment plan–and if you miss any one of them, the client probably won’t return.

Getting on the Same Page

It’s useful to set the stage for brief therapy by letting clients know a little about your approach during the first contact–that you think brief, that you focus more on the present than the past, and that you give behavioral homework. You may tell them a little about your experience to convey a sense of your competence. Once they come to the session, like any therapist, you help them feel welcomed and safe. You can do this by listening carefully to their story and being empathic, subtly mirroring their body position or language to help foster rapport, and clarifying their expectations, either to reinforce them or to suggest alternatives.

But you can’t just listen for 50 minutes and then thank them for coming, take out your appointment book, and say, “Same time next week?” Not in the age of Dr. Phil. You must shape the process by offering direction and leadership, not just responses. This gives clients the crucial sense that you know what you’re doing and where you’re going with them.

However, the most important part of getting off on the right foot is what I call “tracking the process like a bloodhound.” This is where it’s easy to get lazy and lose focus. Clients instinctively want to talk content–to dig through their pile of stories and sort through the heap of facts. Of course, to some extent, that’s important, but you want to focus on what you see that clients usually don’t: what’s happening moment-to-moment in the room. Whether you make a comment or an interpretation or provide education, you need to watch closely how the client responds. Make sure you notice the nod of the head or other indicators of solid agreement. If you hear a “Yes, but . . .” or a lukewarm “That makes sense,” or observe eyes glazing over or a frown, don’t move ahead. Stop and address the problem that’s right there in the room: “Hmmm, you’re making a face. It seems like you may see it differently.”

Gently clarify your thinking, connect your thoughts to the clients’ most pressing concern, and make sure they’re in sync with you throughout the session. If they are and you can offer a clear treatment plan, you’re off to a good start. But if not, they’ll balk or seem uncertain about setting up another appointment. Then and there, you need to realize that, somewhere along the line, you fell out of step.


Changing the Emotional Climate

In a first session, clients are expecting something for their time and money: when they walk out, they want to feel differently from how they felt when they walked in. This is what I call changing the emotional climate. Simply listening and being empathic, allowing clients to vent, goes a long way toward accomplishing this. So does education. Talking to clients about the brain physiology of anxiety, for example, or typical family patterns can help normalize their distress and place it in a larger, fixable context. This is what your family doc does when she tells you that you have an infection or that your rash is simple contact dermatitis caused by the new cream you put on your face. You feel better having a label, an explanation, and a palpable sense of your physician’s educated concern.

In brief therapy, though, you need to ramp it up experientially. One of the most effective ways of changing the emotional climate is, again, zeroing in on the ongoing process with the client. You want to pay extremely close attention to the nonverbal communication, to tap the subtle feelings that are just below the surface. When Sara looks hurt, stop the story and focus: “Hold on, Sara, what just happened? You’re looking sad.” If you say this gently, with real sincerity, Sara may be able to drop her defenses and actually begin to tear up or cry. This open and shared vulnerability will help her emotionally bond with you. You can also do this by asking directly about these often softer and less obvious emotions: “What causes you to feel sad? What worries you the most?” Or ask about positive feelings to offset all the focus on negative ones: “When do you feel your best? What are you most proud of?” By asking, you move to a different level in your relationship with a client and change the climate in the room. Even if Sara seems to push your questions away, you’re still letting her know that you’re noticing how she feels and that this is a safe place to talk about difficult things when she’s ready.

While these points may seem fundamental to being a therapist, I’m always surprised when I see clinicians failing to create this powerful shift. They get too caught up in gathering history for assessment to notice these emotional subtleties, or they rationalize that it’s too soon to tap them. But that’s a mistake.

Linking Problems to Personality

The first question I always ask myself is: What keeps this person from solving this problem on his own? Sometimes it’s because clients have situational stress: they just got fired from their job, they have a medical crisis, their kid got busted for drugs. Normally, they can cope, but now there’s just too much on their plate. They need support and help to be able to zero in on the problem. Other times, it’s a matter of skill or lack of it: they have continual financial problems because they really don’t know how to set up a budget, or can’t talk with their partner without triggering conflict or disengagement. Once you help them understand and implement a budget or master the keys to good communication, the problem begins to fade.

Other problems persist, not because they’re rooted in stress or lack of skill, but are intrinsically linked to their personality and coping style. I think of this from the Buddhist standpoint: How you do anything is how you do everything. In fact, this is where some clients are stuck. While they’re worried about the what–the content of their problems–the real source and solution to their current problem, and many of the problems in their lives, lies in the how, their overall response to problems. This is what I call their core dynamic–an expression of their primary childhood ways of coping, such as accommodation, anger, or withdrawal. While these ways may have helped them survive the challenges of their early environment, now, like outdated software, they’re no longer helping them negotiate the more-complex demands of an adult world.

To move out of the 10-year-old’s perspective and better handle the problems in their lives, they need to update their inner software. More traditional approaches might track this down by a long march through the past, but in a brief approach, you can tackle it in the first session by asking how they concretely and specifically cope with current problems on the job or at home. Of course, you may even detect their coping style during the session itself, through their responses to you.

Once I’ve defined their coping style, I often try to link it to their current problem, helping them see the latest manifestation of the same outmoded response. By doing that, I set the stage for their attempt to challenge their early wiring: instead of being good and accommodating, as they’ve always done, the might push back and say what they need; or, instead of spraying anger around the room, they might self-regulate and use their anger as information. I let them know that they can update the software, which will not only fix their current problem, but prevent future ones.

This focus on defining, understanding, and challenging the core dynamic is empowering for clients. The message is that you can help them map out new ways of taking acceptable risks, breaking old patterns, and acting more like the adult they are than the 10-year-old they often feel like.

Offering a Clear Treatment Plan

Finally, like the physician, you need to leave clients with a clear set of next steps. If you decide the client is stuck because of situational stress, talk about ways of navigating this challenge in the scope of their broader lives. If it’s about coping skills, map out what skills you feel would be important for them to learn. If it’s about their core dynamic and ineffective approaches to problems, or a combination of all of the above, let them know what you’re thinking and what they concretely need to do.

Then, as always, track the process and see what happens next. Does this make sense to them? Do they agree? Do they understand how this is all related to their presenting concern? If there’s a sincere and congruent yes, you may give them concrete behavioral homework to help develop new skills or reduce their stress. If there’s hesitation, ambivalence, or accommodation, stop, clarify, or ask questions until you’re clear about what’s going on. Just remember that their resistance isn’t the problem, but a source of valuable, additional information about what the solution might be. As in any other phase of psychotherapy, it’s hard to go wrong if you bear in mind the clinician’s most useful mantra: track the process like a bloodhound!

Robert Taibbi, L.C.S.W., trains nationally and is the author of more than 200 articles and five books, including the forthcoming Therapy Boot Camp: Brief, Action-Oriented Approaches to Anxiety, Anger & Depression. Contact: bobtaibbi@ntelos.net. Tell us what you think about this article by e-mail at letters@psychnetworker.org, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine.

Distinguishing Behavior from Identity

By Ronald Soderquist

Debbie, who’s in her fifties, called: “I’m so upset about my relationship with my daughter. She and I are always in conflict, and my husband agrees this needs to be changed.”

When she came in, she reported feeling sad because she couldn’t enjoy visiting her daughter, an only child who lives nearby. “It’s such a noisy household. The children scream and squabble; there are two of them under the age of 6. I wish my daughter would be more organized and keep them quiet, so I could enjoy being there. I get so tense, I have to leave her home in the middle of a visit.”

I didn’t have a clear strategy, so I asked her to bring her daughter, Emmy, next time. Then the dynamics became clear. Emmy is a high-energy, outgoing, modern, in-your-face 35-year-old woman. Mother Debbie is quiet, somewhat distant, a loner, who needs her space. I was reminded of the movie My Big Fat Greek Wedding. Mom is a lot like the uptight couple who come into the vibrant Greek gathering.

During the hour with Mom and daughter, it became clear that Emmy wanted her mother to change and just enjoy her high-energy household. “Why can’t you be like other grandmothers, and just come in and enjoy the family?” And Mom wanted Emmy to change. “Why can’t you be more organized and quiet, so I can be comfortable with you? I can’t stand all that commotion.”

First, I tried some conventional strategies, like helping them listen nonjudgmentally to each other, but there was no movement in their relationship. I didn’t see any point in seeing them together again, so I asked Debbie to come in alone.

Again, she told me, “It just isn’t me to be like other grandmothers who get on the floor and play with the children and enjoy all the noise. And I like me the way I am. She’s asking me to be someone I’m not.”

I assured her: “You’re fine just as you are, and Emmy is fine the way she is. You just happen to be very different personalities. She’s AM, and you’re FM: she’s rock-and-roll, and you’re chamber music.” She agreed.

“Fortunately, there’s a solution. I’m thinking about Meryl Streep, and how she takes on a different personality for every role, but off-stage, she’s still Meryl Streep: she doesn’t have to change who she is. I wonder if you’d enjoy inventing a role that works well when you’re with Emmy and her family? (Here, I slowed to my hypnotic voice and watched her slip into a trance.) When you open the door to her home, you can see it like a stage. You pause at the door, view the scattered toys, and listen to the active children as part of a stage set. You may find it amusing. You’re Meryl Streep slipping into a role. Your creative inner mind will be alongside your conscious mind, enjoying the flow as you engage with your daughter and your grandchildren in fun ways, and every time you enter that stage, that family stage, you’ll find yourself expanding into your new role in satisfying ways, sometimes surprising yourself, always enjoying your secret strategy. It’s OK to let your husband in on it. Afterward, you and your husband may chuckle about the relaxed grandmother character you’ve created. You’re both director and actor on this stage. Really enjoy surprising them.”

She came out of her trance and exclaimed: “I can do that!” After some additional mental rehearsal, she left in a very good mood. Three days later, my phone rang: “This is Meryl Streep calling. I just earned an Oscar. I spent a whole day with Emmy and her family, and at the end of the day, my husband asked Emmy, “How did your mother do today?” Emmy said: “She did great!”

It was their first pleasant, relaxed day together in many years, a day without tension and conflict. I asked Debbie what she found interesting while playing her new role. She replied, “I felt so calm–very different–calm and comfortable.” ;

A well-deserved Oscar!

A few weeks later, she called to say, “I’m so excited and happy because I entertained my entire high-stress clan, and did my Streep thing, and enjoyed myself!”

A couple of months later, she said, “I’m so glad I did it. Strangely, now I feel more motherly and understanding toward my daughter than ever.”


Case Commentary

By Steve Andreas

This is a really lovely example of many different important aspects of change work, and the importance of a careful choice of words.

The first session doesn’t offer a clear direction for intervention, so Ronald Soderquist wisely brings in the daughter, so he can observe them interacting, rather than knowing the daughter only through the filter of the mother’s perceptions and report. Although the interaction becomes much clearer when the daughter joins the mother for the second session, having them both together makes it difficult to intervene usefully.

In that session, it becomes clear that, for both of them, the issue is one of identity, in contrast to behavior. Both want the other to change, and each speaks of this change in terms of being different–in contrast to acting different. The daughter says, “Why can’t you be like other grandmothers,” and the mother says, “Why can’t you be more organized and quiet.” (Most answers to either of those questions would lead only to justifications and rationalizations, neither of which would be useful.)

For most people, being different seems to be much more difficult than doing something different. If you describe a certain behavior as “being different,” most clients will object, as both mother and daughter do in this case, and this is one source of what many therapists describe as “resistance.”

As long as both mother and daughter think of their differences in terms of the other having to be different, not much is possible. Demanding that someone else be different is an ill-formed outcome that gets many of us stuck and frustrated, because while you have at least some choice about your own behavior, you really don’t have any choice about what someone else does. That’s why having them “listen nonjudgmentally to each other” in the second session went nowhere, despite how useful that intervention often is.

But if you describe the same behavior as “doing something different” or “acting different” a client will often be willing to consider it. This distinction between identity and behavior is one that many therapists have never learned, and it’s often a crucially important reframe. In this case, it’s the key understanding that allows the mother to change her behavior and have a new internal response to the chaos of her daughter’s household.

In the third session, the mother states even more blatantly that her understanding of the issue involves her identity, “It just isn’t me to be like other grandmothers. . . . I like me the way I am. She’s asking me to be someone I’m not.” That brief utterance makes six references to her identity and five to her being: isn’t, me, be, I, me, I, am, me, be, I’m.

Soderquist begins his intervention by exquisitely pacing her focus on her identity, assuring her, “You’re fine just as you are,” relieving her of any pressure to change who she is, and implying that her daughter’s attempt to change her isn’t valid. He follows this up immediately with saying, “And Emmy is fine the way she is,” which implies that the mother’s attempts to change her daughter are just as invalid. Since the mother already agrees with the first statement, she has to agree with the second, which only reverses the direction of the logic. Abandoning her attempts to get her daughter to be different closes a door that leads nowhere, and opens a door to a more useful alternative.

To strengthen this understanding, Soderquist first offers a generalization about two of them being different. “You just happen to be very different personalities.” Then he follows this up with two metaphors that express this difference in who they are, “She’s AM, and you’re FM: she’s rock-and-roll, and you’re chamber music.” Both metaphors are drawn from contexts in which differences clearly don’t need to change.

He begins his description of Meryl Streep, and the difference between her self and the roles she plays, with the word, “Fortunately,” a cognitive qualifier that creates an expectation of good things to come. If he’d used a different adverb, such as “unfortunately” or “sadly,” the mother would have had a very different expectation about what he’d say next. Saying “there’s a solution,” further directs her attention away from the problem and builds even more positive expectation.

“I wonder if you’d enjoy inventing a role that works well when you’re with Emmy and her family,” is called an embedded question, a hypnotic linguistic form often used by Virginia Satir, one of the greatest therapists who ever lived. Although it’s a statement, it elicits an internal response as if it were a gentle question, but without demanding an overt response the way most questions do. This invites the mother to consider changing her behavior without any demand that she do so, and with no need to respond verbally.

Notice how different an overt question with the same content would be. “Would you enjoy inventing a role that works well when you’re with Emmy and her family?” would demand a verbal answer, and keep her externally focused on Soderquist, making it harder to turn inward and consider whether she could enjoy doing that. The embedded question focuses her attention on whether she’d enjoy playing a role, implying that she can do it; the question is merely whether she’d enjoy it or not. Before, she demanded that the daughter change; now she’s invited to change her own behavior (while keeping her identity intact)–an enormous shift in attitude that most clients can benefit from.

As she begins to consider this possibility, she’ll naturally become more internal, a perfect time for Soderquist to slow his voice to be more hypnotic and set up the specific cues for her new role play–all in present tense, so that she can rehearse it as if it’s happening at the moment. “When you open the door to her home, you can see it like a stage. You pause at the door, view the scattered toys, and listen to the active children as part of a stage set.”

Then he permissively suggests a response she might have, “You may find it amusing,” and follows with even more detailed suggestions that continue to encourage a rehearsal of new behaviors. “You’re Meryl Streep slipping into a role.” The use of “slipping” implies that it will be easy and effortless. Think how different it would be for her if he’d said “trying to get into role” or “struggling to act differently”! He then goes on to suggest other behaviors, and possible pleasurable responses for her.

When he says, “Your creative inner mind will be alongside your conscious mind,” it implies that the creative mind is unconscious and will assist her. As he goes on to say, “enjoying the flow as you engage with your daughter and your grandchildren in fun ways,” it implies that much of this will occur unconsciously and spontaneously. Notice all the words that make this rehearsal an enticing prospect: enjoying, flow, engage, fun, expanding, satisfying, surprising, enjoying, secret.

A bit later, when Soderquist says, “Afterward, you and your husband may chuckle about the relaxed grandmother character you’ve created,” it invites her to take a future vantage point and look back on what she’s imagined, as if it had already happened, further cementing its reality as something she can do. With all this elegant hypnotic language, it’s not surprising that when she emerges from her trance, she says, “I can do that!”

This entire intervention probably took less than four minutes, showing that when you know what to do–and how to do it–change is easy.

I think Ronald Soderquist deserves an Oscar, too!

Ronald Soderquist, Ph.D., a hypnotherapist and licensed Marriage and Family Therapist, is the director of Westlake Hypnosis in the Los Angeles area. He’s served on the staff of California Lutheran University and other universities and graduate schools. Contact: eldaron@earthlink.net.

Steve Andreas, M.A., has been learning, teaching, and developing personal-change methods for more than 53 years. His books include Virginia Satir: The Patterns of Her Magic; Transforming Your Self; and Six Blind Elephants: Understanding Ourselves and Each Other. His new book is Transforming Negative Self-Talk: Practical, Effective Exercises. Contact: andreas@qwest.net.

Tell us what you think about this article by e-mail at letters@psychnetworker.org, or at www.psychotherapynetworker.org. Log in and you’ll find the comment section on every page of the online Magazine.

Parenting Skills: NP0027 – Session 6

Teach parents a new way to praise and encourage their children while getting them to comply and overcome difficulties by shifting the focus from “problems” to helping kids gain meaningful new skills. In this approach, parents will take on the role of guides and cheerleaders and children will gain confidence in themselves. Ben Furman, psychiatrist and trainer of solution-focused psychotherapy, will explore this method and take you through case studies.

After the session, please let us know what you think. If you ever have any technical questions or issues, please feel free to email support@psychotherapynetworker.org.

Parenting Skills: NP0027 – Bonus Session 2

Consider the enormous psychological and cultural impact of today’s digital technologies on children, adolescents, parents, and society in this enlightening address with renowned MIT psychologist Sherry Turkle. You’ll discover that our smartphones, laptops, tablets, social media sites, and other electronic gadgets have a deeper impact on us as individuals, families, and society at large than we might have previously realized.

After the session, please let us know what you think. If you ever have any technical questions or issues, please feel free to email support@psychotherapynetworker.org.

Parenting Skills: NP0027 – Bonus Session 1

Explore the effects that overprotective parenting can have on children with Michael Ungar, director of the Resilience Research Center and author of 11 books for therapists and children. Discover how parents can best offer children opportunities to experience risk and responsibility while ensuring their safety and give them boundaries without suffocating them, increasing their anxiety, or reinforcing their need for rebellion.

After the session, please let us know what you think. If you ever have any technical questions or issues, please feel free to email support@psychotherapynetworker.org.

Men in Therapy

By Rich Simon Not long ago, my wife, Jette (who just happens to be the world’s best couples’ therapist), and I were about to begin one of the several couples weekend workshops we hold every year. One of the men in the group approached Jette during an early break, obviously in real distress. “You must change the sign downstairs in the lobby,” he hissed in her ear. Read more

Attachment Theory in Practice: NP0028 – Session 3

Learn how new research about mating and bonding can contribute to your understand of what secure, integrated sexuality looks like. Join Susan Johnson as she explores sexual problems and how they can best be addressed with clients.

After the session, please let us know what you think. If you ever have any technical questions or issues, please feel free to email support@psychotherapynetworker.org.

Today’s Wisdom: NP0029 – Session 1

With this webcast session we ask ourselves how do we recognize, and share with our clients, the “Wisdom” we have gained. Join Ron Siegel as we discuss how to lay the groundwork of transformation to activate our overall awareness.

After the session, please let us know what you think. If you ever have any technical questions or issues, please feel free to email support@psychotherapynetworker.org.

Parenting Skills: NP0027 – Session 5

Bullying has fallen more and more into the media spotlight lately. Is it that kids are becoming more aggressive? Or are we just paying more attention to this phenomenon? Is it the new forums available for these kinds of behavior—21st-century technologies that can make it easier to kids to bully? How can therapists, parents, and schools help the child who’s being bullied? Learn with Stan Davis, the co-leader of the Youth Voice Research Project, about how to focus on resilience in the child who’s being bullied and to help strengthen their support communities, in addition to working to stop the bullying behaviors.

After the session, please let us know what you think. If you ever have any technical questions or issues, please feel free to email support@psychotherapynetworker.org.