Thinking of starting therapy and feeling unsure about the process?
What it is & what it is not.
From the practitioners perspective, a first session is the time and place to set the frame for future sessions. During this session, the practitioner will also perform an intake assessment.
The first session may form part of a number of initial sessions, as the assessment may take place over more than one meeting. For example, practitioners may allocate their first three sessions with a client to assessment and “setting the frame” of the therapeutic relationship. Within the first session/s, a practitioner may use this time to get to know the client and better understand the client’s needs and goals for future sessions. In addition to this, first sessions are also a time for clients to become familiar with the practitioner and the therapeutic space. This allows both the client and the practitioner to gauge whether the relationship will be comfortable and has the appropriate fit for both parties. The process is ultimately to get a more holistic view of the client and what they are struggling with.
Further, the first session/s can allow the practitioner the opportunity to complete a full assessment in order to arrive at an appropriate clinical diagnosis and/or recommendations for the clients best interests. This can often take time, as practitioners strive to be thorough in their assessment before coming to a final decision on the diagnosis.
Practitioners and clients need to manage expectations around the first session/s. It will not necessarily feel like a solution nor provide all the answers. While some may feel more comfortable and relieved immediately, others may not. It is not likely that you would receive a diagnosis within the first session, if at all. Practitioners would be making a make rushed decisions if under unrealistic time constraints and run the risk of misdiagnosing a client, which should be avoided at all costs. Clients should not be discouraged by the process if there is no clinical diagnosis; this does not mean that there is nothing for the practitioner and client to work on. For example, clients may display depressive symptoms that may not meet the full diagnostic criteria and therefore be sub-clinical for a certain diagnosis.
In a first session, clients can expect some paperwork. This is necessary as practitioners need to provide the client with information prior to them signing an informed consent and intake form. The practitioner should explain confidentiality and the client will be informed about when, and under which conditions, confidentiality can be broken as well as the duty of the practitioner in an emergency situation. This would include situations where the practitioner believes that a client is at risk to themselves or to someone else. Emergency plans would also need to be addressed and put into place during these initial sessions.
A written screening may form part of the paperwork involved. Additionally, some practitioners may insist on a screening phone call, which can be helpful and reassuring, to both parties, especially if seen online for the first appointment. The pre-screening methods are put in place in order to determine whether the practitioner would be acting in the clients best interest to continue with booking an appointment or to determine if it is appropriate to treat online.
The typical format of a first therapy session
Remember that as a client, you do not need to be overly prepared as most practitioners will lead the initial questions in the first few sessions. It is completely normal to experience some anxiety around the first meeting. The approach the practitioner chooses to take may vary but would typically start with the basics. Here, practitioners need to ask for clients age, where they stay, and who they are currently living with. These questions often lead to the context of their current situation, for example why they are staying with certain people and not others etc. Thereafter, the practitioner can ask clients about their work or study and other significant relationships in their life.
What else would my practitioner need to know:
- If there is a psychiatric history (possibly in family as well)
- If you’ve had previous contact with a psychologist
- If you have ever been formally diagnosed with a mental illness before
- If you are on any current psychiatric medication, and for how long
- Any serious psychiatric admissions (whether short- or long-term; [in]voluntary)
- The reason the client is seeking assistance, and why now? This is to assess whether there was a certain precipitating factor
- Medical history, and how it’s affected you (this can also help to rule out certain diagnoses or make further recommendations for medical follow up etc.)
- If there is current or past substance use
- Past or current loss or trauma (might only be covered at a later stage if it was not a current trigger)
- Practitioners need to assess risk of harm to self or other and would need to know about suicidal thoughts and thoughts of harming others (current and/or past as well as self-harm)
- More about your basic bodily functions (i.e vegetative symptoms)
During the assessment, the practitioner may also try to arrive at therapeutic goals with the client, but this may take time and only become clear in later sessions.
Let’s be real
The first session will almost definitely evoke emotional responses. Although the initial feeling after the first session could be relief, the client can commonly feel very exposed thereafter; as Brene Brown calls the “vulnerability hangover.” What happens is that often the client comes to terms with the fact that they have verbalized their struggles, and that they now need to face and process the emotions that come along with it. During this time, clients may feel the urge to distance themselves; to guard or defend against these raw emotions which can often translate into resistance in continuing with session two. We as practitioners know this and remember these feelings are normal and valid and can absolutely be brought to a second session. Your ambivalence is welcome here.
Within the initial sessions, practitioners would make the client aware of the requirements for continued sessions. This would include defining their contractual relationship as well; this is done to protect the confidentiality of the client and set appropriate boundaries. For example;
- a session cancelation policy
- how the practitioner will normally communicate with the client
- what times the practitioner is available
- the office times of the practice
- how payment works
- how to handle situations if they see the client outside of a therapeutic setting
This may be communicated via email or during a phone call prior the first session but would often be reiterated for clarity before continuing with follow up sessions.
In conclusion, practitioners will have the appropriate training to ask what is needed and will often adapt this to follow the lead of their client. All of this confidential information helps the practitioner to best assist you and helps to form the therapeutic relationship between practitioner and client.
Amy Glover is a practicing Clinical Psychologist based in Cape Town. She has her masters degree in Clinical Psychology and Community Counselling (cum laude) from the University of Stellenbosch. She divides her time between a private practice in Vredehoek, Cape Town and developing practitioner-led resources to equip professionals to navigate online platforms for mental health services. She is passionate about preventative mental health and works with individuals and couples. Amy Glover is available to see clients online for therapy. Email: email@example.com or contact here.