How is the first therapy session structured? - Chapter 6

This chapter will discuss the first session and what is important.

What are the goals for the first therapy session?

The goals for a therapist for the first therapy session are:

• To establish rapport and trust with the client, normalize their difficulties and instill hope.

• Socialize clients into treatment by educating them about their disorder, the cognitive model and the process of therapy.

• Collect additional data to help conceptualize the client.

• Develop a goal list.

• Start solving a problem important to the client.

How can these goals be accomplished?

To accomplish these goals, the following format is used:

1. Initial part of session 1

   • Set the agenda. By setting the agenda the client knows what to expect. The therapist must make sure that the client agrees with the topics he/she set on the agenda. The therapist must explain the rational for why the agenda is set at the beginning of the session. In this way the client will collaborate more actively and the session will be more productive.

   • Do a mood check. The therapist asks the client for a brief narrative report of their mood since the last time they saw each other. This can be in the form of a question during the session, but a client could also fill out a form before the session starts.

   • Obtain an update. The therapist asks the client if there are any important problems or issues that might not yet have been discovered. The therapist can decide which problems are urgent to discuss by asking how distressed a client is by the problem. Long-term, or chronic issues can usually postponed to future sessions. After this, the therapist asks if anything positive happened last week, this will help clients see the reality more clearly.

   • Discuss the client’s diagnosis and do psycho education. Most clients want to know their diagnosis, and to establish that the therapist should emphasize that they are not abnormal or strange. For personality disorders it is better not to label it, but describe it. It is also desirable to give clients some initial information about their condition, so they can start attributing some of their problems to their disorder, instead of to their character. The therapist will explain what their disorder is about and can eventually give homework to read a chapter about their diagnosis at home.

2. Middle part of session 1

   • Identify problems and set goals. The therapist helps the client to turn their problems into therapy goals. The client can write these goals down, so that he/she will remember them during therapy. It is also good to create one general goal for therapy in behavioral terms. It is important to also identify aspirations and values of the client. Values are long-standing beliefs about what is most important in life. It shapes the choices and behavior of people. When people perceive they are not living up to their values, they often become distressed.
     Besides the clients' aspirations and experience, the meaning that clients put on aspirations and experiences is also important. 

   • Educate the client about the cognitive model. The therapist will help clients understand how their thoughts have an influence on their behavior. The therapist can explain this model using the clients’ own examples. Also do activity scheduling here or work on an issue. The therapist will try to show the client that there are different ways of viewing the issue and the therapist can provide the client with concrete steps in solving problems. This will instill hope in the client that the therapy might work.

   • Set a new Action Plan together and check on likelihood of completion.

3. End of session 1

   • Provide or elicit a summary.

   • Review homework assignment. The therapist makes sure the patent knows what to do. If the client seems to doubt if he/she will be able to do all the exercises, the therapist should offer to change it. It is important that the client will feel successful in making the homework; otherwise it can contribute to their low self-worth.

   • Elicit feedback. What did the client think about the session and the therapist? This feedback can be given in verbal or written form by filling out a form. Shows that the therapist cares about what the client thinks, this strengthens rapport.