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In Consultation

In Consultation

By Dan Short

First Impressions
Getting off to the right start is crucial in therapy

Q: Some clients connect with me more easily than others. How much can a professional do to foster a good therapeutic "fit" with every client?

A: There's a lot you can do—and the faster you do it, the better. In a matter of minutes, new clients will decide how good your relational fit is, and whether to return for more therapy. The first impression is created by the earliest interactions. Even unconscious signals from clients determine how much self-disclosure and emotional risk-taking they'll engage in during the first session, how much benefit they've experienced, and whether they'll return.

For example, a recent client walked into my office and stood distractedly, not knowing what to do. I invited her to sit across from me on the couch. When I asked her why she'd come to see me, she said she'd seen another therapist the previous day, but didn't think she'd return because she didn't feel "understood." I asked her what she'd discussed with the other therapist, and she replied that he'd asked her about her feelings. Following this exchange, she sat passively on the couch, gazing at me, politely waiting for her next set of instructions. So I asked her to tell me the worst thing that had happened to her in recent months. Cocking her head to one side, she said, "Now there's an interesting question. Let me see. I guess it would have to be last week, when my husband put a loaded gun to my head." Out of curiosity, I asked, "Did you happen to mention this to the therapist you saw yesterday?" Again, she gave a quizzical turn of the head. "He never asked, and so I guess I just didn't think to bring it up with him." The previous therapist didn't have much of a chance at success with this client because he failed to engage her properly during the first few moments of therapy.

Clients shouldn't have to adjust their style of relating to fit the therapist: a skillful professional should continually adapt to the interpersonal needs of each client. This ongoing process is informed by three basic questions: How much direction does this individual need? How much emotional intensity is this person prepared for? And what thoughts, feelings, or actions is this person showing me right now that I can use to form a connection?

To Direct, or Not to Direct?

In the example above, the first therapist might have been working from a client-centered model of empathic equality, in which the therapist strives to be as nondirective and noncontrolling as possible. This is fine, unless the therapist is seeking to help a client who needs direction, as this woman did. When she entered my office, she was confused and didn't have much self-direction. Therefore, she needed a therapist who'd tell her where to sit, ask specific questions, and help her figure out her problems.

On a different occasion with another client, I listened to bitter complaints about his first visit to a previous therapist, who, he said, "told me where to sit and how to think." Working from a cognitive approach, the therapist instructed the client to replace illogical and self-defeating thoughts with more realistic and helpful ones. The client felt that this therapist didn't let him talk about the things he wanted to talk about. During my first visit with this man, I mostly sat and listened—not offering any direction until close to the end, when he asked my opinion. He was an artist and extremely temperamental. Rather than asking him to tell me about his problem, I asked him to draw it. This was a request that he thoroughly enjoyed fulfilling.

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