Mental Health, Therapy General

(Sitting down this morning to write be like, “Okay, what do I feel awake and caffeinated enough to tackle this morning, writing a plausibly-coherent blog post, or trouble-shooting my office technology? …Ah, guess I better write that post, then.”)

In an entirely non-scientific polling of my own personal FB feed, “what to expect from a first session” and “red flags for choosing a therapist” were two top requests. I don’t often write about the technical aspects of sessionwork simply because there are almost as many variants on the “how” as there are therapists in the field. “How” is then dependent on their individual style, possibly the modalities they practice, definitely any policies of the practice in which they work (especially applicable to groups, agencies, and larger or corporatized organizations, like hospitals and clinics). There are a lot of articles available on the topic of what to expect and on the subject of spotting red flags in your therapist.

As a friend pointed out, this being my blog, maybe it would be useful to describe a little of my own process. (I will point out the irony of running with that suggestion, given that a therapist talking predominantly about themselves is a Big Red Flag, but hey, you’re not paying me for this hour, so Imma take the mic for a while 🙂

Pre-session, there are different ways in which clients contact me in both my solo practice and through Bliss Counselling. In my solo practice, clients contact me directly, usually by email, and I get a chance to ask for a VERY high-level idea of what kind of issues they’d like to work on, so I get a sense of whether or not those subjects are in my wheelhouse, and then I will email them my own intake forms. At Bliss, our wonderful admin staff are the first line of contact, so they’ll ask those questions on the therapist’s behalf, possibly help incoming clients set up a profile in our online management system, and send prospective clients a link to the assessment form that has a ticky-box list of potential issues. I’ll review that before an intake session. Once a first session schedule is set, we’re off to the races.

The advantage of almost fifteen years doing this is that by now I have a well-practiced introduction. I’ll greet the client warmly, make sure I’m pronouncing unfamiliar names correctly, and welcome them into the conversational space whether it be in-person or virtual. I like to ask right up front whether they’ve done any kind of counselling or talk therapy before; their answer determines how much of the spiel I’ll need to give on the general therapeutic process.

If they’ve never done talk therapy before, I’ll keep it light and simple, and describe the collaborative process: them sharing as much or as little as they feel comfortable with, especially given the awkwardness of talking to a stranger, then me offering back what I think I’m hearing to make sure I understand what I can about their current situation and maybe a little about where they’re hoping to get to through therapy. I’ll describe how I use that to determine at least a starting point for whether I have a useful skillset for the work they want to do, so in the moment I might be able to offer some perspective or suggestions for potential work we might be able to do together. I suggest that depending on how much information the client wants to share in the initial session, I may or may not be able to get to that point of offering reflections, but I should at least be able to get a feeling of whether I’ll be a useful tool for them or not.

I will talk a little bit about how I work therapeutically, about my background training and the general approaches I take, but only if the client seems familiar or interested in hearing that upfront. I will explicitly offer to talk in more detail about what I can do, in the context of the conversation as it unfolds. My biggest concern is that I don’t overburden the conversation with a lot of details that might not be relevant to the work the client wants to do. I do, however, invite questions at any and every step of the process. I describe how I definitely invite a 2-way conversational approach; therapy often works best as a collaborative effort. I may bring the clinical perspective and experience to the table, but the client is always not only the Subject Matter Expert in their own experiences, but they are the “boots on the ground” field-testing and reporting back on any change processes we explore in session. I try to avoid positioning myself as The Authority; especially as a therapist, I’m much more comfortable in the role of co-author.

And perhaps most importantly, I tell the client that I don’t consider first sessions like this to be an indication of commitment on the client’s part; especially at Bliss, our admins like to ask new clients to book 2-3 sessions in advance just so they get time on our calendars (some of us tend to book up quickly and fairly far ahead). People who are new to therapy may feel like that ties them to us and obligates them to continue with a therapist they’ve only just met. I prefer to reassure them that I’m treating a first meeting like a test drive, so the client can get a feel for the process and my style; if they don’t feel like they can be comfortable with me, I’m going to wind up spending more time dealing with their resistance to me than with the issues they want to work on. So if I’m not the right partner for those conversations, I would rather help them find someone who will be.

I will tell them both at the beginning and end of the session to take a few days, a week, whatever they need to let the dust settle after the first conversation–especially if it’s been an emotional experience for them–and THEN think about how the conversation went, before making any decisions about working with me or not. I want my clients to be in the best headspace they can be in to make a choice like that. We don’t often get the same opportunity to be so deliberate in choosing who we work with in support of physical or mental health. I want to drive home the idea that the client always has the right to say NO in this work, including saying NO to working with a specific therapist.

My preamble done, then I yield the floor to them. I ask the client to tell me a little about themselves, the glossy-brochure bio details of who they are, general family or work details, any interests or hobbies or passions they have. This starts to give me an idea of the major players and influences in their lives as a whole, and background to the issues bringing them into my office. It’s the front door into the conversation about where the client themselves locates their current challenges. And at this point, I’m drinking from the firehose.

As I describe it to clients, at this point I am collecting every piece of information I can, because I don’t yet know what will be relevant and what will not. I ask a LOT of questions here, sometimes for clarification, sometimes to suss out whether I think a pattern is forming. I liken it to collecting children’s wooden letter blocks into a bag; at some point, I will upend the bag and put the blocks together to see what they might spell out. I’ll then toss that perspective out to the client to see what resonates or not. Things that resonate for the client, we stick to the mental wall as a “working theory,” a combination of what they have experienced and what I suggest from the clinical perspective as potential explanations or reframing. I’ll use these later to help me determine what tools might be useful in the context of what the client wants to change.

I may or may not do what I call the Family of Origin Snapshot, a quick relational genogram of their earliest influences and role models if it seems relevant. For example, FoO information is enormously valuable to me if the client is struggling with value conflicts, internalized narratives and self-judgments, or issues that feel like they’ve been around since childhood. (A genogram structure can also be an extremely useful tool for clients dealing with work stress, but in that case, I usually just refer to their literal Org Chart.)

And then, or somewhere in the deluge of information that is a first session, I ask my Magic Question: What does “better” look like? This is where the work begins. This is North Star by which we will set the work’s navigational compass, the point on the other side of the gap. When I do check-ins with the client down the road, the answer to this question is what we use to determine congruence in the work we’re doing: are we actually moving towards “better”, or have we come adrift of that defined goal? (The goal can change over time, but that’s not something we’re typically going to worry about in the first session.)

If I have time, this is the point where I talk about clinical approaches, what I bring to the table, and what I can offer in collaboration with those stated goals. If I don’t think I have the right tools for something that’s beyond my scope, I’ll make that very clear and offer some ideas for things I think MIGHT work that the client could look into, or assistance with referrals if necessary. But if the issues are in my wheelhouse, here is where I talk about the work I think I can help with, looking at attachment issues, stress and burnout coping strategies, internal narratives and other intrusive fiends, relational communications, intimacy issues (to name a few things in which I have been known to dabble).

There’s a lot of compassion and empathy on tap in that first session. Clients rarely come to us when things are going well in their lives, so respecting and reflecting on their challenges and struggles has to be a part of that space we create at the outset. I am a big fan of Carl Roger’s unconditional positive regard. I also try to pick out and mirror back some of the client’s own strengths, especially if they seem like they’ve become detached from them; that’s a callback to my days doing Solution-focused Brief Therapy; I try to give the clients back a sense of something positive in themselves on that first meeting. Reminding them they have strength never hurts, even if therapy isn’t something they decide they’re ready for, or I’m not the therapist they want to work with.

As we wrap up the initial conversation, I give them a chance to collect themselves if it’s been a rollercoaster first session, and we move things back to simpler, shallow waters talking about potential next steps (booking, billing, etc.). I will remind them they are under no obligation to return. I encourage them to take some time to reflect before they decide; like investing in a car, you want to make sure it not only has all the bells and whistles, but you want to ensure it has the drive handling and capacity you need. Therapy is an investment in ourselves, our health and wellbeing. We’re NOT stuck with whomever we draw in the lotto. And sometimes, making an active decision for themselves about who they will or won’t be vulnerable with, is the first self-empowering choice a client has been able to make for themselves–in a long time, or possibly ever. That idea alone deserves some mad respect.

Then I walk them out, let them know they’re welcome back on my schedule any time they’re ready, and offer them a warm goodbye. And I will always be delighted when they choose to come back and get into the work with me.

Mental Health, Therapy General

A regular meeting with one of my students this morning got us looking at two different types of therapist approaches to meeting and getting to work with clients. Both are valid methods of navigating intake and the early stages of information collection, and good to have in the therapist’s toolbox. It might also help clients understand why they click better with some therapists than others, and help them define what they’re looking for if they’re currently shopping for a therapist.

Most of the time people come into therapy because they are dealing with a specific problem, or experiencing a specific set of symptoms even if they don’t yet understand why. During an intake process, they’re meeting the therapist for the first time, which means two things are happening simultaneously:

  • Stranger meets stranger
  • Information changes hands

Establishing Rapport

Many people think of therapy in much the same way as they think of medical doctors: they have a problem, they go tell the professional, the professional gives them something to fix the problem, and hooray they’re cured! (Or at least feeling better.) This is historically the medical model for feeling better, and sometimes leads people to wonder why they can’t get a fix in the same ten minutes it takes a doctor to diagnose a set of patient-reported symptoms. Talk therapy doesn’t always work like that, but some models, like Short-term Solution-focused Therapy, do aim for a similar kind of immediate relief of at least the symptomatic distress.

Therapists are trained to understand what clients come to learn with experience: that perhaps the biggest factor in therapeutic “success” is the rapport established between the client and the therapist. That rapport is all about the relationship these individuals create through the process of sharing space, information, and (hopefully) empathy. Some folks don’t want to take the time to build a relationship, they just want the fastest resolution to their current discomforts so they can go on with their lives. Some people will only allow themselves to open up about experiences once they have established a degree of trust and safety with a therapist. This leads us to approach the work with our clients through either a Problem-centric focus or a Person-centric one.

Problem-centric Focus

This morning I was reflecting with my student on how they are developing their own clinical approaches, drawing on various learning resources through their training. They currently have an intake form they use to guide the first few client conversations that is very focused on gathering information about the problem: the symptoms, their perceived severity and persistence, the level of impairment the client experiences because of them. Only after digging into the details of the problem does the form expand into more general information about the client themselves.

This kind of approach puts the PROBLEM(s) front and centre and focuses the ensuing conversations on those pertinent details. This is a really useful approach if the therapist has only a limited number of sessions (or a one-off situation, as with a walk-in clinic), and needs to understand “where does it hurt the most?” or “where is the client seeking the most relief?” It’s also an effective approach with clients who are focused on fast resolutions and strategies rather than long-term self-development. Reflecting after this morning’s supervisory meeting it occurred to me that this is also probably a useful approach for student and novice therapists who need to determine as early as possible whether the client’s presenting issues are within the therapist’s limited clinical experience and scope of practice.

On the downside, it also presents a bit of a sandtrap to therapists operating from a “just fix it” mindset. The temptation is to label and categorize the problem without digging much into context or broader influencing features in order to go straight to symptom management… and in doing so, perhaps miss a lot of important information about influences on the client’s broader condition. In short: you’ve mitigated the symptoms but potentially done nothing to address or even acknowledge the actual problem.

Person-centric Focus

My own approach to those first client conversations is to get to know a little bit about the client themselves. I’ll ask if they have any previous therapy experience, or what they think therapy as an experience entails. I’ll ask them to tell me a little bit about themselves and tell them a bit about myself in return, though I generally weave any kind of detailed descriptions of how I work into the conversations about their challenges. Especially with people new to psychotherapy, I have less risk of getting lost in trying to describe clinical interventions to someone who has zero idea WTF I’m talking about, no context for what I’m bringing to the table. So I leave that until I can find ways of showing how I might apply what I know directly to their own issues, and let the contextualization do the heavy lifting for us both. I get a good sense this way of how the client talks and how they listen, what kind of language they respond to, and I have a chance to watch and mirror some of their body language (even in virtual meetings). If I can get a basic sense of them in the first few minutes, THEN I’ll ask what’s bringing them in to talk to “someone like me.”

I’m not a doctor; I’m not trying to bulldoze 25 clients a day through my office in ten-minute increments or less; I can take my time and get to know who’s sitting in front of me. (It also helps that I’m personally someone who loves drinking from the information firehose. I often describe my process in those first couple of sessions as gathering all the seemingly random bits of information the client chooses to share, and all the information they don’t even realize they’re sharing via word choices, speech patterns, and body language. I collect it all and sort it out as we go, pairing the client’s information with my observations and clinical experience to come up with working theories I can pitch to a client to see what resonates, and what makes them feel like I’m understanding what they’re sharing.

This type of approach puts the PERSON first and foremost and helps orient the therapist towards the person having difficult experiences before digging into the issues themselves. Focusing on the person is also useful when the client is in emotional distress, if the therapist can use mirrored body language and vocal tones to calm or counterbalance the way the client’s body or voice shifts as they get worked up. It’s not that we ignore the issues so much as we establish that rapport first, a person-to-person connection to put the client more at ease. It helps create some sense of safety (hopefully) for the client to talk about hard things, and to receive compassion and input from the therapist. It’s a style of approach that very much invites the Person into the room, not just the Problem.

The Person-focus approach has its own traps. It’s easy to misread clients who really just want solutions and strategies, if they’re genial enough to engage in the “getting to know you” patter, and in doing so, leave them feeling like you’re not serious, not taking them seriously, or taking to long to get to what they came for. Focus on rapport-building is often a slippery slope for therapists falling into their own biases and risking over-association or over-sympathizing with the client; this is a space in which we run a high risk of transference and countertransference occurring between client and therapist as we try to establish connection and empathy without always having good boundaries right up front.

Not every client is going into a first session with a clear idea of what they want or need from the conversation they’re about to have. Inexperienced clients generally can’t describe what they want from a therapist, other than, “Fix me so I feel better”–the same request they’d make to a mechanic to fix their car so it runs better, or to a doctor so they can feel physically better. Therapists have to develop almost a sixth sense for what live performers call “reading the room”: the ability to suss out a client’s level of (dis)comfort with talking about their issues and asking for guidance or help. Are they here for a quick strategy session, or are they here to unburden for the very first time a lifetime’s worth of relational chaos? (I haven’t yet figured out how to teach reading the room as a therapeutic skillset. It’s just a thing many of us do semi-intuitively.) But once we have that sense we can choose the most effective approach out of the toolbox, and off we go to the races.