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 three goals to meet: getting on the same page, changing the emotional climate, 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.
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. 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!
This blog is excerpted from "The Art of the First Session" by Robert Taibbi. The full version is available in the November/December 2012 issue, The Rise of Therapeutic Coaching: Is The Game Changing?
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