The process of therapy has many steps, and begins before the client comes for the first appointment. Below are several steps and some tips on managing them.
The client's first inquiry is often a phone call or email about the possibility of therapy. You should express interest in working with the client, and set up a time to meet. As clients often decide to come to therapy after matters have reached a crisis, they may expect to see you immediately, and so an appointment the same or next day is often helpful. Some will suggest at least a phone appointment for 15 to 20 minutes the same day if a face-to-face meeting is not possible in order to calm the anxious client, and assess for any risk of harm to self or others.
It is important to realize that the client may be anxious, upset, or in turmoil when they come for their appointment. You may be the therapist to see them, but you may be an intake worker or evaluator who will assess and assign them to the appropriate therapist. If you will not be able to see them for therapy, let them know at the outset (i.e., "I'll be seeing you to briefly interview you about the stresses and problems that bring you to therapy, and then will determine which professional here at our center/group/agency will be best able to help you."). If you will likely be the one to see them for therapy, let them know you are available, but don't rush into recommending they start therapy. They may need to talk a bit, and get a sense of who you are, before deciding to see you for therapy. Be sure to explain what therapy is, how it works, and answer questions about what the client can expect from therapy in general and from therapy with you. Some of this is basic HIPAA procedures as required by law, and some is basic informed consent procedures as required by our ethical code. However, this is also part of a process that establishes the therapist as a partner in the client's therapy, and as someone who is open and transparent about the process.
The Start of Therapy
Therapy begins with a first interview. This is a discussion (though one heavily weighted toward the client's side) that reveals bit by bit the person seeking therapy, they way they think and function in the world, and the most important characteristics of the world in which they have to live. It is a relational process, where the therapist, as a person, directs the process and communicates verbally and non-verbally what therapy is like. They "listen" to what is said and not said, what is communicated in verbal and in non-verbal ways. Sullivan notes that many patients become annoyed when the therapist asks "obvious" questions, and suggests that therapists should explain they are interested in the client's unique perceptions. Different people experience "obvious" stresses and make "common sense" choices for a range of different reasons. He also recommends constantly assessing whether your questions and the client's answers have alternate meanings. For example, the therapist may ask "Where do you live?" based on an assumption that the client has a stable residence, and the client may answer with a given neighborhood or area based on an assumption that the therapist will assume certain things about them based on where they live. The client may ask "Are you married?" based on an assumption that the therapist will not understand the client's problems without some frame of reference, and the therapist may answer based on the importance of such a question given their theory.
Sullivan and others have also written about the meaning of the payment for the service of psychotherapy. Sullivan notes that the payment is all that the therapist receives from the therapy, perhaps in addition to a sense of having helped the client. He stresses this as keeping this basic element of the therapy relationship clear from the outset helps the therapist maintain a sense of clarity about boundaries and the role of the therapist. Since Sullivan, others have noted the role of the therapist as an agent for social change who helps clients step back and see their role as a part of a large and complex social and economic system; this allows them to make some choices about their behaviors and functioning which they might not recognize otherwise. Others write about the therapist as a representative of society who informs client's of their rights in therapy and may even report on the client's progress in therapy to courts, or who is held accountable by society for predicting risk for violence and harm to others.
Sullivan breaks up the first interview into four stages:
- The Inception is the beginning of the interview. The reason for referral, greeting, previously reviewed information, and ethical concerns of confidentiality and informed consent are discussed during this stage.
- The Reconnaissance entails gathering information about the problems and stresses that bring the client to therapy.
- The Detailed Inquiry entails gathering specific and detailed information from the client, separating relevant from irrelevant information, and understanding the balance of problems and stresses compared to resources and strengths. This can include, for example, knowing what the client has tried to resolve problems before, and asking what has been helpful and what has not.
- The final phase is Termination, the end of the interview. Two things happen in this phase. First, this is when the therapist closes the process for the client, as opening up memories of traumatic events, discussion of seemingly hopeless problems in their current life, and recalling past failures and mistakes can leave them feeling worse than when they came in. Part of what the therapist does is help them close up some of these processes and return to daily life, and part is helping them leave behind these feelings for the next session. Second, this is when the therapist in effect invites the client back to work on the issues that cause them distress and unhappiness. For some clients, the first appointment is the most difficult, as it entails considering and explaining things they would never discuss with others. For other clients, the second appointment is actually the most difficult. Coming back means committing to a process, placing trust in a stranger, and experiencing some hope that therapy and work with this therapist will be helpful. While some therapists do not try to determine how the first appointment ends, some do try to end the first session on a "hopeful note," one that inspires the client to believe that they can make changes to be happier in their lives.
The Initial Interview, Do's and Don'ts
- do not argue with, minimize, or challenge clients. Even if the client says something that is obviously distorted, do not attack or challenge their views, as you likely are pushing them to face something they are not ready to face, and telling them in effect that therapy is about being pushed to face unpleasant things
- Do not praise clients or give false assurances. They he may be unable to accept any praise, even if sincerely offered, and feel therapy will be a "feel good" process rather than a "working" process. There is a difference between making false promises, and offering hope that the client can and will be able to change their life.
- Do not interpret the client's words or actions to the client, or speculate on the dynamics underlying their personal functioning or the functioning of those around them. If the client is not ready for this, it can again feel as though therapy is about confronting them with things they do not feel ready to face. Even if they are ready, this can cause the client to think the therapist is quick to diagnose people or problems without knowing all the facts. This is ironic, as the therapist does this based on the client's report of the facts. Thus, for the client to view the therapist as prone to making quick judgments without all the facts is itself making a quick judgment without the facts. It is also a way for clients to avoid considering that they may not have given the therapist all the facts. This is not unusual, however. Do not join the client in attacking others. Showing them that you can be nonjudgmental of strangers, even when the "facts" seem clear, indicates you can also be nonjudgmental of them.
- You might decide to offer one, simple, non-threatening interpretation in order to test the client's insight. This allows some evaluation of clients' ability to accept some personal responsibility for problems, to focus on problem even when doing so is uncomfortable, or to acknowledge that problems may be larger or more complex than they realized. This can be very helpful in assessing how ready he client is for therapy, and thus how "fast" the process of therapy should progress.
- Do not offer a diagnosis. Sullivan cautions that this may weaken the client's self-esteem. However, consider that this may make the client feel judged in some sense (i.e., "There's a name for people like me?") and fear that the therapist will reduce them to "just a diagnosis." Also consider that in this day and age, clients can google a diagnosis. They may learn very accurate information, but may learn very very inaccurate things about their diagnosis and the therapist's view of them, possibly causing further distress. Remember that diagnoses were designed for doctors to communicate essential information quickly and efficiently to other doctors; they were not designed to be shared with patients.
- Do not interrogate clients on sensitive areas of their lives. While they may talk openly with some people about their sexual desires, childhood, and work lives, they choose when and how and with whom they do this. They may need time to be sure the therapist will not judge them.
Newer therapists may feel taking notes helps them remember the content of the therapy session, and this is likely true. However, part of the therapist's job is also attending to the process of the session. This, taking notes can be distracting for the therapist (and client). However, taking notes allows you to record information verbatim, record important details and information without relying upon memory, and produces written proof of the session and the information it contained. Further, there is a social psychology term known as confirmatory search strategies, meaning we search for information to validate what we already think. Thus, we tend to remember information that made us think we were right, and forget information that might have made us think we were wrong.
Collecting Information from Clients
Keep in mind that clients seldom answer their therapists' questions completely and fully. This happens for several reasons:
- Clients usually do not know what is and is not important to therapists. They may believe some thoughts and feelings are quite normal, or that everyone experiences the same things, and so they may not have the perspective to think otherwise.
- Clients may not want to reveal certain things until they are sure they can trust their therapists
- Some things are emotionally painful to face, or require insight and understanding to recognize. As a result, clients may not face these things not as a way to deceive their therapists, but rather as a way to deceive themselves. They may not realize patterns, triggers, or signs and so are not able to report them.
Resistance is a way clients protect themselves from painful experiences. Sometimes is has been seen as an impediment to therapy that should be challenged, but other times it has been seen as a healthy and natural process in clients that therapists should work with. When a client becomes resistant after working well in therapy, it may signal to therapists that they have moved too fast in therapy, missed some key issue, or failed to appreciate the clients' experiences in some very important way. For example
- A teenager may come to therapy, but sulk and refuse to talk, as engaging in the process might feel like admitting they are psychologically flawed or damaged in some way, or the sole cause for the problems in their lives. The therapist might offer "maybe you feel angry about being sent here," or "maybe you feel you do not need to be here."
- A man might come to therapy, but consistently deny any psychological problems. The therapist might ask why he came, and be told that others told him to come to therapy. The therapist might offer that his problem seemed to be with these other people, and begin focusing on why these others see a problem and what the client wants to do about these perceptions. This avoids making the client take ownership of a problem that may or may not be their fault, but also moves the therapy toward finding some area both therapist and client can agree on and working from there.
Clients may also ask questions about the therapist's life, training, and experience. This could be resistance to the treatment, but could be an effort to determine whether the therapist can help, and whether the therapy environment is safe. The therapist can reflect back issues, and provide some information.
The client may come to therapy with several needs:
- the need to be dependent and receive sympathy and understanding (social support)
- the need for unqualified acceptance and validation (unconditional positive regard)
- the need to reveal painful feelings and ideas; while Freud called this catharsis and felt it was not therapeutic, others disagree and believe that "lifting" or "sharing" an emotional "burden" is a powerful form of healing in and of itself.
- the need for education about an illness, which often makes a problem seem less threatening, confusing, and powerful, and offers some hope.
- the need for transference, or to work out a problem with another person who will set aside their own needs long enough to help clients understand and resolve their conflicts.
The therapist fills many roles and needs in clients' lives. The therapist may be a helping authority who educates, an idealized parent who heals past hurts, an actual parent who remains constant while the client works through resentments and unhealthy patterns, or a supportive person when lovers and friends are missing. Therapy may take anywhere from several sessions to several months to several years. Thus, building a therapeutic relationship is a dynamic process is different for different people, and changes over time as people's needs change. It requires great initial attention but also ongoing care and maintenance. The therapist communicates:
- understanding of the problem
- interest in the person as a person
- sometimes reassurance and sympathy
- tolerance and acceptance
- freedom to experiment with different values and beliefs, without judgment or pressure
- objectivity about problems but empathy and understanding for the person experiencing them
Do your best to avoid:
- exclamations of surprise, overconcern, or doubt
- flattery and praise
- moral judgments or criticisms
- expressions that may be interpreted as punishment, impatience, false promises, bragging, or threatening
- expressions that maybe interpreted as blaming or rejecting
- quick interpretations, advice, dream interpretation, and psycho-babble
This is perhaps the most basic skill of any therapist. Rogers argues that reflective listening is a poor term, as it involves much more than just listening. It is an effort to understand someone's feelings and world view, make sure your understanding is correct, and offer your understanding in a way that makes sense to the client from their own world experience and view and is free from the therapist's personal distortions. It requires:
- open-ended questions (can you tell me more about that?)
- allowing the client to determine important areas for inquiry and the nature of his problems
- a non-judgmental and accepting approach
- talking less, listening more
- reflecting back the essence of feelings and experiences instead of the content of statements
- remaining cool, calm, and patient
- remembering that your understanding of the client may be wrong or incomplete
Therapists may care little for the DSM IV, and instead diagnose to understand:
- first line defenses, or things everyone does to maintain control over tension and anxiety, such as sleeping, using substances, seeking pleasure, and engaging in fantasy and daydreaming
- second line defenses, or characterological behaviors, such as excessive dependency and submission, domination and aggression, withdraw, narcissism, and compulsions
- third line defenses, or repressive responses, such as reaction formations, over-reliance on intellectualization and rationalization, blunted emotions or apathy, disturbed consciousness and memory, and phobic reactions or obsessions
- fourth line defenses, or regressive responses, such as helpless dependency, withdrawing from reality, mania, internalized hostility