What are the elements of a good initial session in therapy and how do I go about structuring one?
The initial session is the first opportunity for us to establish a therapeutic alliance with our clients and gather important information that will inform the treatment process. The initial session sets the stage for the rest of therapy, and we must approach it with care and professionalism.
I used to tell my clients that initial sessions are not like regular therapy sessions. They are about me getting to know you and the problem better so I can go away and devise a plan to best assist you. My first sessions are very structured, with a set of questions that I deem as 'essential' to know, and others that are 'nice to know' if time permits.
The point of an initial session is to gather enough information to develop a case formulation and treatment plan. This ensures we are using evidence-based methods and taking the time to consider the person and the problem and tailor treatment to suit them as an individual.
Here are some tips for conducting an effective initial session:
Establish a Therapeutic Alliance: Building a therapeutic alliance is one of the most critical aspects of the initial session. Psychologists should create a warm and welcoming environment, establish rapport with the client, and communicate their approach to therapy. Don't lose sight of this while conducting your clinical interview!
Gather Information: The initial session is an opportunity for psychologists to gather important information about the client's history, symptoms, and goals for therapy. This information will be used to develop the case formulation and treatment plan.
Assess for Urgency: Psychologists need to assess for risk in initial assessments. Does this person potentially pose a risk of harm to themselves or others? Ensure you are competent in risk assessments and safety planning, as this skill is vital for psychologists and saves lives.
Explain the Therapy Process: Psychologists should explain the therapy process to the client, including the number of sessions, frequency of appointments, and what modality of therapy you will be using. This helps to set expectations and establish a clear understanding of the therapy process.
Obtain Consent: Psychologists should obtain informed consent from the client in the initial session, including explaining confidentiality and any limitations to confidentiality.
Schedule the Next Session: The initial session should conclude with scheduling the next appointment, discussing homework assignments, and reviewing follow-up procedures.
But what are we looking for exactly in an initial assessment?
Here are my must-knows:
Past/current history of psychological problems and diagnoses
Family history of psychological problems
Are they being medicated for a psychological condition or other condition which may cause symptoms of a psychological problem? (To learn more about psychopharmacology click here).
What is my diagnostic hypothesis (if relevant)? This includes completing a symptom checklist and reviewing psychometric screeners with my client. This helps inform my treatment plan.
Substance use history and current status
Have they been to therapy before? If so, did they find it helpful? Why/ Why not?
As mentioned above, is this client at risk of harm to themselves or others?
What are the thoughts, feelings and behaviours associated with the problem?
What are the triggers and modifiers?
What is currently reinforcing or maintaining the problem?
What did their life look like/ how were they functioning when they were 'well'?
How do they perceive the problem started?
How do others in their life respond to the problem?
What are their goals for therapy? What do they hope will get better or be different?
Here are my nice-to-knows. If I don't capture these in the first session, I know I will likely gather this information during treatment:
Early childhood/ life history- family dynamics growing up, history of their relationships (peer and romantic), academic and work history, any other significant life events
An account of why/how these problems have developed (Predisposing Factors)- You will likely have a working hypothesis after the first session.
What are the client's Core Beliefs that are shaping the way they experience this problem?
Critical incident/Precipitating factors- and did the client put an adverse construction on the precipitating events?
In the initial session, you want to get enough information about the presenting problem and the perpetuating factors so that you can develop a treatment plan. I want my first session to be thorough yet succinct enough to capture this information and not put my client through an assessment process that takes several sessions. Our clients often come to us in a state of distress, and therefore, I want to get started with treatment as soon as possible (by the second session, ideally).
The initial session is a critical component of the therapeutic process that sets the stage for the rest of therapy. We are establishing a therapeutic alliance, gathering important information, and laying the foundation for a successful treatment experience (all in the space of 50 minutes!)
If you're interested in a structured approach to your treatment, I've got a therapy manual for depression that has detailed session templates, guides, and client handouts here. I'm also running a group supervision session: "Elements of A Good Initial Session" in may where I will be talking about this topic more in-depth. You can book that session here.