How I Start My First Session

Icebreakers, Alliance-Building, and More

Psychotherapy Networker

It’s said that first impressions are everything. Perhaps nobody knows this as well as therapists, for whom first introductions with clients can be make-or-break moments that influence therapy sessions to come. In a first meeting, how do you break through a client’s tough exterior? Convey concern? Build rapport? Here, three therapists share their guidance.

1) Never Underestimate Small Talk

I see a lot of couples, which means a lot of reluctant men. Knowing and anticipating that many men are likely to feel apprehensive about therapy guides my opening moves. Our first moments together are crucial.

Many men benefit from therapeutic transparency, so I load them up with information before they’ve even walked through the door. Along with a note confirming the appointment, I send detailed instructions with information about fees, insurance, and even where to park. I also give both partners a detailed questionnaire in advance of our first session, so each person can describe the problems that have led them to therapy. This doesn’t only inform me, but sends the message that we’re going to be focusing on specific issues, not just wandering around in the wilderness of feelings.

When I usher a new couple into my office, I always make small talk. I have a big fish tank that they’ll often comment on. I’ll ask them if they were able to find my office, which is in an old house, circa 1907, and joke about our petite parking lot. I used to resist small talk, thinking it interfered with setting the right tone, but over the years, I’ve learned it’s a prerequisite.

Afterward, I ask both partners, “So what are the two of you doing here today?” If they’re vague, I focus the conversation by saying, “Usually when a couple sets up an appointment with me, something has just happened. Maybe it’s something dramatic, like an act of aggression or infidelity. Other times it’s something more common, like a painful argument or communication breakdown. What happened recently that led you to pick up the phone and call me?”

And we’re off.

David Wexler, PhD
San Diego, CA

2) Create a Shared Space, Even from Afar

I’ve found that clients’ first experiences in therapy often determine whether they’ll return and how much they’ll be willing to disclose. Like so many other therapists right now, I’ve switched to doing teletherapy, which requires that we pay extra attention to creating an environment that allows first-time clients to trust us. The good news is that creating this environment is very possible.

In my teletherapy sessions with first-time clients, I’ll greet them by name, introduce myself, and tell them it’s great to see them. I’ll also ask where they are and if anyone else is in the room with them, just to ensure their privacy. Next, I’ll offer some insight into what we’ll be doing in this first session and subsequent ones.

As a mind-body therapist, I share a little bit about myself and my modalities, including breathwork and mindfulness. Usually, I’ll ask them how they’re feeling in the moment. Are they experiencing any discomfort? If so, first, I’ll normalize it, assuring them that many new therapy clients feel this way.

I might say something like, “Whatever you’re feeling right now, I’m here with you.” I’ll remind them to breathe, and may even provide a brief breathing or grounding activity to help them calm down. “We’re a team,” I’ll tell them, “and I encourage you to ask questions and share if there’s ever something that I’m saying or asking you to do that you don’t agree with.”

From the start, I want to help clients understand that therapy is a shared space, even if we’re not in the same room. I give them a virtual tour of my office, introducing them to the singing bowls, essential oils, and sage that I might use during sessions. Finally, I invite clients to create a healing space of their own to enjoy.

I’ve found activities that show clients up front what some of our work might entail are extremely important. Our clients choose us because of who we are and what we have to offer, and they deserve to experience that regardless of whether we’re meeting in person or virtually.

Daphne Fuller, LPC
Fayetteville, NC

3) Less Interview, More Conversation

I often work with teens and adolescents. In first sessions, they can be suspicious, guarded, unpredictable, or sometimes even hostile. But over the years, I’ve learned that fear and anger can be contagious. Even though a teen I’m working with may be angry, that doesn’t mean I have to respond in kind. Rather, I demonstrate respect and acceptance, which I’ve found melts away resistance so that we can get to work together.

If a teen (let’s call him Kevin) is in my waiting room with a parent, I’ll greet the teen first, treating him as my client—even if he’s doing his best to hide, sitting four seats away from his mother, legs splayed, and a hood pulled over his head. “Hi, you must be Kevin,” I might say, stretching out my hand. “Nice to meet you, and thanks for coming in.”

As we move into the office, I’ll tell him to sit wherever he’d like. Then, I explain why we’re here. I might say, “Kevin, your mom called me last week and asked if we could meet,” then turn to his mother and ask that she briefly elaborate. If Kevin happens to glance up to gauge my reaction, I’ll be sure my nonverbal response reflects interest and concern for both him and his mother.

When Mom finishes, I’ll turn to Kevin and say something like, “I’d like to talk to you alone for a little bit to get your perspective on things if that’s okay. But before we do, I’m not sure if you’ve ever talked with a therapist, so I want you to know exactly how this works.”

I find that teens are often quite attentive when confidentiality law and its limits are explained to them. If I get eye contact at this stage, I respond warmly. Once the parent understands what I will and won’t keep secret, they’re asked to wait outside. Then, I turn all my attention to the teen. Now that we’re alone, I’ll step away from the problems that brought him in and focus on his experience: How’s he feeling about being here today? Has he ever seen a therapist before? When did he find out he was coming in? What does he think about therapy? Has he had other experiences with adults in helping roles?

Then, I’ll flip the script and focus on his likes and strengths. I might ask questions like, “What do you like to do for fun?” “What do your friends say about you?”  Or “What kind of music are you listening to right now?” I might share something I’ve heard about his favorite artist and offer a little of myself to help us get to know one another, which sets the stage for more openness and honesty later. The less I can make this part feel like an interview and more like a conversation, the better.

Only then will I dig a little deeper. I might say, “Would it be okay if I ask a few questions to get to know you better? If I ask anything that’s too personal or you’d prefer not to talk about, just let me know and I’ll back off. First, would you like to talk about the problems your mom mentioned or any previous experience with therapy?”

Too many teens tell me about ineffective interactions with helping adults who try to talk them out of their threat response. We owe it to them to demonstrate patience and respect for their thoughts, emotions, and behaviors from the very beginning.

Britt Rathbone, LCSW-C
Bethesda, MD


Topic: Creativity | Professional Development

Tags: Alliances | body and mind | body mind | challenging clients | clients | counseling teens | couples | Couples & Family | couples conflict | couples counseling | Couples Therapy | couples therapy techniques | David Wexler | engaging teens in therapy | kids | mind and body | mind body therapist | Mind/Body | Mindfulness | rapport | teenage counseling | teens | therapeutic alliance | therapy for teens | treatment for teens

Comments - (existing users please login first)
Your email address will not be published. Required fields are marked *


Friday, May 28, 2021 9:45:14 AM | posted by Matthew Lundquist
This article gives me chills. I'm eager to hear from other therapists. Is this much business and over-tending the norm? Nearly all of what's purported here appears to be indistinguishable from the values of polite customer service, the goal of which is to complete a financial transaction as smoothly and quickly as possible with as little drama and emotion as possible. But drama and emotion are the very stuff of psychotherapy. In these clinicians' rush to make the new patient feel safe they minimize room in which the feeling of not being safe might present itself. In training new therapists I often do an exercise where we role play just this--what to do and say at the start of a first session. Nearly always the therapist is filling much too much space, working much too hard to assure the patient that she/he/they are safe. After a few minutes, perhaps with a few taking turns in the therapist's chair, I prompt the colleague playing the patient to reveal why they came to treatment, which we determined in advance: Two days earlier they'd been raped by a roommate. They're frightened, unsure who to trust, the roommate is pretending it didn't happen. This patient arrived at the intake unsure of how to talk about it, unsure if she even will. The question I put to the group of new therapists is this: Did you engage in the session in a way that would leave room for that to become known? Or did you feel space in such a way that both therapists and patient could pretend that everything was safe. I'm reminded of this from Wilfred Bion: “In psychoanalysis, when approaching the unconscious – that is, what we do not know – we, patient and analyst alike, are certain to be disturbed. In every consulting room, there ought to be two rather frightened people: the patient and the psychoanalyst. If they are not both frightened, one wonders why they are bothering to find out what everyone already knows.”

Tuesday, May 12, 2020 8:27:39 PM | posted by Nicholle
Ms. Fuller made quite the impression on me during the first time I attended a mediation class she was guiding. It was the reason I returned for more sessions.