The First Session

Have a plan, and know when to let it go

⧖ 3 minute read

What do I do in a client’s first session?

In rough order, we’re trying to: 

  • Help clients feel welcome, comfortable, and safe

  • Go over informed consent to counselling

  • Role induction, discuss expectations, the pros/cons of any previous therapy experience that may inform how we work together now

  • Start building the alliance and help them see if you’re a good fit

  • Hear their story so they feel understood and validated, and continue doing so until:

  • They invite you to help them (which may not happen this session, or at least not til near the end)

Step by step: I greet the person then chat on the way to my office, though for first sessions I give a casual tour on the way (generally, fit small talk in here so it’s out of the way by the time you get to the room).

An example of what I’d say when we sit down: So, the important thing we’re going to do with our time today is hear from you about what’s bringing you in. Before we can do that we need to cover informed consent to counselling, so I’ll talk you through it and any questions you have. [then do so for a few minutes]

I know things are a bit front loaded today, sorry. I just need a few more minutes so we’re well set up for this work. I think it’s important that we discuss expectations and roles. I think it’s my role to help you feel comfortable, and I think it’s important that we work together. It’s foundational to good therapy that we make sure we’re focused on things that matter to you, but it can be easy for me to mess that up: if I misinterpret you, if I start just giving advice, or if I take our conversation to a subject that you don’t find meaningful—please let me know, okay? I don’t want to waste your time. 

I think a helpful way to think about therapy is similar to a music lesson. If you’re trying to learn how to play guitar but the only time you ever picked one up was during your lessons, you’re not going to get any better. So you’ve got to practice. Same thing here; I hope our time together is helpful, but quite a bit of the work of therapy happens outside of session. Does that seem fair?

As a quick yes or no, have you done any therapy before? What did you find helpful from those experiences that you think it would be useful for me to know? Anything you didn’t like that I should stay away from? Before we dive in, any questions for me or about this process?

So, tell me, what’s bringing you in? Then I practice active listening for 1 to 40 minutes. Continue listening and asking good questions until your client ‘invites’ you to help them. Invitations are the moment when it seems like your client is done explaining their main concern(s) and they say things such as:

  • So I’m just not sure what I should do…

  • So that’s what I’ve been going through, and what I’ve tried to fix things, but it hasn’t seemed to be working

  • I’m not sure if you have any input for me?

  • I need advice

  • What would you do in my situation?

  • What should I do?

Invitations can look quite varied, but once you get experience watching for them, it’s usually pretty easy to ‘read the room’. Trying to jump in with an intervention before the client is ready signals you’re not tracking your client or in tune with them, which leaves people feeling misunderstood. Admittedly, the invitation may not come until they advance in the stages of change, so once they’ve told me the main concern I start subtly transitioning into questions that can shift them in that direction. New therapists can be nervous or excited and jump in with an intervention, but I encourage you to simply make a note to yourself for later and keep exploring and validating. Once you know what to look for, you’ll see this constantly in sessions: how awkward and deflating it can be when done poorly, or how trusting and engaged clients can be when it’s done well.

Other things to keep in mind: 

  • Risk assessing, if it seems indicated. I suggest doing so around the half way point or earlier— so you’ll have enough rapport when asking. Many clients under-report the seriousness of risk, so I find more rapport leads to more transparent answers here. You need time to deal with it if it’s serious, so don’t wait too long, and generally there will be organic moments to ask more about it

  • I almost always draw a casual genogram while they’re telling me their story, asking a few quick questions at a reasonable time later in the session to detail it further

Yalom has a great interview where he discusses first sessions:

Yalom: It’s very important for you to take risks, I think you should try to do that every session, the more risks you take the better work we’re going to do. We can return to this later in sessions.
Yalom: I’ve been aware of this session, of things being a little different than they were last week. Remember what I told you about taking risks? How close have you come to taking a risk this session? 
Client: Maybe I came close in this [x] moment
Yalom: oh, could we go back to that moment and see where you could go further?

I highly suggest you record a first session if possible, or at least role play it with colleagues: get their feedback. While the bare bones of what I cover is similar to many of my colleagues, their first sessions look quite different than mine and they all still do great work. Everyone does this differently. Some people have a shorter or longer informed consent discussion, some people try to just be warm and friendly for a few minutes to build rapport before starting.

I figure people are paying (a lot) to see me for only 50 minutes, so we should get to business, and it sets all kinds of useful expectations: it indicates I’ll maintain healthy boundaries, respect their time, that we’re here to be as honest and direct as possible/as they’re comfortable being, and so on. It’s not the ‘right way’, but it’s authentic behaviour for me.

Follow your local ethics and codes of conduct, find something that fits your personality, and practice. First impressions matter, good luck!

TLDR: safety, consent, role, then listen until invited

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