May Quandary: As a clinician, I often find the start and end of therapy to be a little awkward. Not only do I struggle with first sessions, but last sessions, too! Anyone else? What are some ways you've made your first and last sessions less uncomfortable?

 


1) Words to Live By

In the first session, I like to build a foundation by laying out three rules. First, the client has to acknowledge that something is happening in their life that isn’t serving them. Second, they have to accept the level to which that thing negatively affects their life. Third—and most importantly—they have to give themselves permission to act on their own behalf, meaning they have to believe they’re worthy of doing and feeling what they need to do and feel in order to move forward. I tell clients this foundation builds on victories they've already achieved, like choosing to come to therapy. I might say something like, “I want to address that it took a lot of courage to come here.” It gives the treatment momentum.

I also remind clients at the beginning of therapy that they’ve created a life for themselves based on expectations—theirs and other people’s—and now that they’re seeking to change it, this will likely mean reestablishing boundaries, like saying no to people they’ve always said yes to. I tell clients that throughout their healing journey, they’ll inevitably meet both subtle and overt resistance, but I add that they must consistently remind themselves that they’re seeking change for themselves, not for other people. I tell them that their pursuit of happiness and peace isn't a weapon being used against someone else, and that they shouldn’t let anyone tell them it is.

Toward the end of therapy, I give my clients a list of words and phrases to be mindful of—words that regularly work against them in insidious ways: could, should, always/never, but, I don’t know, and supposed to. The word could, I tell them, implies that they have a crystal ball, a DeLorean that reaches 88 miles per hour, or that they can read minds. I tell them that none of these things are true. The word should, I tell them, is a shame-based word that suggests a place or condition where they’re already supposed to be. I tell them always and never are “absolutes” used to describe subjects they've mistakenly decided are immune to change. But, I tell them, is a magic sentence eraser. I don’t know is usually driven by fear. And supposed to is a shackle-like expectation that we and others place on us without permission.

Although I consider myself more of an emotional tugboat—the real steering wheel is on the client's ship—this process has helped me point clients in the right direction. 

Donn Bradley, AMFT, MA
Brentwood, CA

 

2) The Power of Rituals

I find beginnings and endings so valuable in the therapeutic experience. When I first bring a client into my consulting room, I say a little bit about the space, like “This space is a container for your feelings” or “you can say anything you want here.” I speak about confidentiality as well. On the wall in front of where my clients sit, there’s a poster of a path in a forest. I tell my new clients that other clients often choose to look at it when we talk. I have water available, and let them know they’re welcome to it. I ask how they’re feeling today, and if they’re nervous we begin with some gentle breathing. Then, the conversation begins.

Usually, the client has much to say. If they're coming to me for a specific reason, we’ll address that. Often, clients have a variety of concerns, and most of the time in the first session I just let them get them all out. Occasionally, a client will say they’re not sure why they’ve come to therapy, so we'll brainstorm together. I’ll ask questions about how they’re sleeping and eating. I’ll ask how the past couple years since the pandemic have been for them. Eventually, we'll spark something. I know that some therapists start by sharing a bit about themselves or describing their therapeutic approach, but I like to demonstrate that I’m here to listen. If a client seems apprehensive about treatment, I make sure to check in with them halfway through the session to see how they’re doing.

I also find space in the first session to ask the client to visualize him or herself a year from now and how they’d like to see themselves. This can often help clarify what needs to be accomplished in therapy. 

Regarding the end of therapy, I find it very important to spend the closing session speaking to what has happened for the client over the past couple months. I set aside some time for both of us to speak to their strengths and future challenges. I encourage them to tell me which parts of therapy they found useful and which they didn't. I talk about how they appeared in the beginning of therapy, as they’re almost always calmer and more self-aware at the end.

I also have a closing ritual. On the windowsill in my office, there’s a small scarf, some beach rocks, and affirmation stones with different words like hope, strength, or courage etched on them. I'll ask the client to choose one, and tell them that what they chose has been part of their therapy journey, and to keep it as a reminder of how far they’ve come. Then, we discuss what they chose, and I tell them that whatever meaning they’ve derived from the object was in this room all along, when they were feeling good or bad. I also do this in teletherapy by showing clients a photo of the scarf and rocks, having them choose one, and then sending it to them in the mail. I’ve found it’s something my clients really appreciate.

Cindi Gray, LCSW
Bandon, OR

 

3) Ending with a Wish

Although I’m now retired, I developed a good process for beginning and ending therapy. I always told my supervisees that the first session starts the moment you greet the client in the waiting room. After calling their name and introducing myself, I always tried to find something about them to comment on. I might say, “I really like the color of your shirt,” or “those are great earrings!” It isn’t difficult to find something that lets the client know you see them as an individual.

Once in my office, I’d talk about confidentiality and expectations around attendance, and made sure I’d fully answered any questions the client might have about those details. I also talked about what they could expect from therapy, and gave them permission to be honest about what they thought, felt, liked, or didn’t like about therapy.

I always worked for an agency, which meant I had to do intakes in the first session. I’d tell the client that the initial session involves a lot of information gathering and history taking, and that they’d be free to talk more about what they wanted to cover going forward. From there, I’d ask what brought them into therapy. Whenever I had to ask uncomfortable questions about subjects like abuse or substance use, I’d try to preface these questions by saying something like, “This may be difficult or uncomfortable to answer, but it’s important to know so I can be helpful to you.” Toward the end of the session, I’d ask them what their goals were and help them get specific in articulating those goals. Finally, I’d ask, “Is there anything else you think I should know?” and thank them for giving me so much information and let them know that next time they’d get to set the session agenda.

It’s always bothered me that we don’t seem to pay as much attention to ending therapy as we do to beginning it. When ending therapy, I always liked to set an agreed-upon end date several sessions in advance, when possible. I found this easier in group therapy, and for many reasons setting an end date wasn’t so easy when it came to working with individuals and families.

As therapy is ending, it’s important to reflect with the client on how they’ve changed and how the therapeutic relationship has changed. Reminiscing about hard parts and successes is part of the process. It’s also important to help clients come up with a plan to deal with feelings and behaviors that might get triggered in the future. I used to tell clients that my goal was to work myself out of a job, because it would mean they’d have developed the skills and support systems to weather any storm.

I also liked to leave clients with a wish as they went forward. I’d try to frame the wish in a way that pointed them to things they could do on their own after therapy ended to continue the growth they’d achieved. I’d express confidence that they could leave therapy and live a decent life, provided I really believed that was possible. I’d wish them luck in dealing with whatever lay ahead, remind them that they had skills they could use, and offer an open invitation to call and check in if they needed help down the road.

Babs Schmerler, LCSW, CAC III
Montrose, CO

 

4) Trust, Empowerment, and Validation

First and last sessions can be rewarding experiences for both the client and therapist. I find that explaining the therapy experience up front and being relaxed helps clients feel less nervous and uncertain. One of the first things I talk about is confidentiality, and how in therapy we might talk about anything and everything, including childhood, relationships, gender identity, sexuality and sex, family, friendships, work, body image, dreams and nightmares, anger, abuse, goals, and trauma. I say that since we might talk about such personal things, trusting me and feeling safe is vital, because if they don’t feel safe, they won’t want to talk—or even show up for therapy.

The trust piece leads me to the importance of the therapeutic alliance. I tell my clients how research shows it’s the most salient factor in a client feeling like therapy is helping. I make a point of telling clients that if they don’t feel like I’m the right fit for them that they should feel free to say so, period. Therapy, I say, is for and about them, not me. I say lightheartedly that I’m not saying I hope they’ll think I suck, but rather that I hope they’ll feel comfortable enough to want to work with me. Still, I want them to be empowered from the get-go and speak up. This has never failed to put my clients at ease right off the bat (plus it also sets the stage for doing feedback-informed treatment).

In my last sessions, I review what brought the client to therapy in the first place and what their goals were then compared to now. I name their strengths, make a point of identifying positive attributes, and review the progress they’ve made. I tell them it was a privilege to walk alongside them for part of their journey. Often, I’ll tell them I’m proud of the work they’ve done and encourage them to be proud of themselves as well. Finally, I’ll ask if there’s anything they want to say about their experience or if they have any feedback for me.

Therapy, like all of life, is impermanent. Not all clients will have a final session—many don’t want the discomfort of an actual goodbye—but for those who do, it can be a blessing for them and for us.

Nancy Johnson, LMHC, LPC, NCC
Needham, MA

 

5) Follow the Energy

Energy awareness, physical and emotional, is critical to effective therapy beginnings and endings. We see energy in clients’ verbal and nonverbal expressions, and I strive to maintain awareness of this process, for myself and my clients.

I begin therapy by first validating the client’s decision to seek treatment. I express support for their willingness to be vulnerable, embark on personal exploration, and create personal change. I do this by welcoming them to my practice, acknowledging their specific reasons for contacting me, and discussing the therapy process. I try to remain mindful of my nonverbal behavior during this time, as it determines the effectiveness of what I’m saying and communicates my level of support and acceptance of my own vulnerability with someone I’ve never met before. I try to be aware of and follow the energy of the client and myself, and try to convey a readiness to assist without being uncomfortably invasive. 

At the same time, I try to get the client to disclose some of what’s troubling them and get some their history. I do this by using the Ecomap assessment. The Ecomap is a document that uses eight areas of functioning, demonstrated by circles on a page with headers, so the client can immediately see the topics we’ll be covering during assessment. I provide information about the assessment phase as well, which communicates that the client and I will be working as a team. Building rapport and trust at this point is essential. I try not to rush the process, but I do keep it moving. If I’m doing a session via telehealth, I’ll show the client my notes periodically and at the end of the assessment. Last, we discuss and clarify their specific goals in therapy.

I also periodically discuss termination with my clients, timing these conversations based on their progress and cues that they’re close to being ready to terminate. This often happens when clients choose to space out their sessions, after they’ve met most of their goals.

In my final sessions, I like to review the reason the client came to therapy, their goals and progress (or lack thereof), and their future plans for using the skills they’ve learned to address their problems. Based on the client’s situation, we might discuss the opportunity for them to return to therapy if they feel the need to. Last, I validate their participation in therapy and invite them to share their thoughts about the experience.

The last session may elicit a variety of feelings from the client and therapist, and it can be challenging. I’ve found that following the client’s energy and my own, taking stock of the dynamics of our shared process, and accepting where the client is can be so important to a good ending.

Janice Sandefur, LCSW, ACSW
Ocala, FL

 

 

6) Look for Parallels

There are often so many domains to cover in a first session with a new client that it can be a bit daunting. I want to learn as much about their goals, history, and symptoms as possible while simultaneously working hard to make a positive connection, providing feedback about treatment expectations, and infusing some hopeful prognostic projections.

One thing I always do in a first session is keep an ear open for special interests, hobbies, skills, or strengths that might serve as a potentially meaningful metaphor to use in future sessions. For example, if a client is a musician, actor, or athlete, I might tuck that detail away knowing we might eventually talk about therapy progress being like learning a new music number or athletic skill, or the importance of practice, patience, and repetition. Learning new skills in therapy can difficult at first, and often takes practice. If a client happens to be a coach, teacher, tutor, babysitter or mentor, I find we can make a connection between the work they’re doing encouraging others and their ability to engage in similar self-talk when it comes to setting personal goals or offering themselves gentle, nonjudgmental support. Sometimes special interests can be a jumping off place for connection and valuable analogies. When a client mentions a favorite movie, fanfiction, or series character, it can be a pathway for exploring traits that inspire them and thinking of ways to playfully incorporate them into their own progress. These personal nuggets aren’t always apparent in first sessions, or always useful, but they can become very valuable to future work.

Knowing when to end therapy often isn't as clear as knowing when to begin, especially given variables like deciding to taper sessions, shifting to seeing clients as-needed, and ghosting. However, I do think it’s important to have a clear timeframe for termination, as it makes space for the important relational ritual that is the last session. Aside from addressing the client’s progress, their remaining intentions, and relapse warning signs, I like to give something tangible to clients in our last session as a small but concrete token of our work. It might be a printout of a quote we often said together, a laminated piece of paper with a favorite visual metaphor, a sheet of stickers with encouraging words, or a note highlighting the growth I witnessed. For many clients, this serves as a souvenir from an important personal journey. My clients are often touched to receive these, and seem to immediately understand the meaning behind it.

Sandra Wartski, PsyD
Raleigh, NC

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Next Month’s Quandary: Many of my clients have mentioned how troubled they are by the recent spate of school shootings. Like so many people, I feel like I'm at a loss for words. What can I do to help my clients manage their pain, anxiety, and frustration?

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