The First Therapy Session: A Guide for Clinicians

Therapy can be intimidating, especially for first-time clients who are new to the psychotherapy setting and may feel nervous about the experience. However, providers can ease the process by starting off the therapeutic relationship with a level of organization that takes away a lot of the guesswork for clients, freeing them to focus on progressing toward their goals.

Building an optimal first therapy session for clients includes addressing needs that arise before, during, and after the meeting has concluded. Relevant examples include:

• Completing administrative tasks before the first session
• Building an understanding of the client’s goals and needs for therapy
• Ensuring that your specialties and expertise align with their needs and expectations

Before the first therapy session

Handle all relevant administrative tasks before the first session

Clients will need to fill out certain documents so you have all the information necessary to add the client to your practice. Relevant information includes:

1. Insurance and payment

If you accept insurance, details should be handled before the first appointment so any concerns regarding insurance are handled beforehand. Providers can also encourage clients to enroll in auto-pay to lessen the likelihood of any missed payments down the line.

If you don’t take insurance and rely on cash pay, let clients know what will be owed for the first and subsequent sessions, that payment is due at the time of service, and consider saving a card on file for all clients.

2. Intake forms

Intake forms allow providers to share all important information as it relates to their practice and should clearly state practice policies and procedures. Clients should sign these forms prior to beginning treatment. Intake forms should include but aren’t limited to:

• Clinical Intake Questionnaire
• Email/Text Consent
• Informed Consent for Assessment and Treatment
• Notice of Privacy Policies
• Telehealth Consent
• No-show / cancellation policy
• Procedures for charging credit cards, including fees

3. Clinical assessments

Assessments create a baseline understanding of the client’s health and track their progress between sessions. Two relevant clinical assessments include:

• Depression Assessment (PHQ-9)
• Anxiety Assessment (GAD-7)

Be transparent on communication boundaries

Whether in your intake forms or in your email/text communications with your client, you’ll need to include specific information that lays out clear guidelines and expectations regarding communication. This means detailing your preferred methods of communication (email, text, etc.) as well as setting expectations on which hours you’ll be available for contact.

Clinicians should notify clients that they'll utilize only HIPAA-compliant platforms to communicate with clients, and should not use personal cell phones for communication, as these are not HIPAA-compliant.

Clinicians must also set expectations around the kinds of communication that are appropriate between sessions, and hours when they will be available to respond, as well as guidance for seeking help in case of emergency. Establishing healthy boundaries is essential for providing high-quality clinical care, and for staving off the negative effects of burnout, which is a growing issue among providers.

By setting professional expectations beforehand, providers are in a better position to avoid issues related to emotional exhaustion and overload from work.

Assist clients by sharing tips on how to prepare  

When posed with the question, “How to prepare for your first therapy session?” Alma member Ayana Ali, LCSW, offered these three suggestions that should be added to every clinician’s playbook. You can send these tips to clients by email before their first session to aid the client and your therapeutic process.

Watch Alma’s video linked here to learn more about helpful tips to share before the first session.

1. Emphasize the importance of honesty

Therapists should create a context in which transparency feels safe for clients, while also respecting that clients may need to build trust over time before disclosing highly sensitive information.

2. Tell clients to be themselves

When clients are encouraged to bring their full selves and speak from authentic life experiences, you’ll be better able to understand their perspectives and their needs. This can ultimately translate into clients being able to build healthier boundaries and relationships with other people.

3. Explain that therapy is a marathon, not a sprint

As in other areas in life, making progress in therapy takes consistent effort and dedication. Clients should understand this before they begin investing their time. Make it known that they shouldn’t feel as though every one of their problems must be addressed in the first meeting.

During the first therapy session

Use the first session as an opportunity for mutual learning

“A fundamental balancing act that you’re always dealing with is how do you balance getting sufficient information while establishing sufficient rapport. Because if they don’t come back for a second session, the treatment is surely a failure.” (Victor Yalom, 2014)

During the initial session, both the therapist and the client will begin the process of learning about one another and agreeing upon a plan for therapy.

Providers will want to familiarize prospective clients with information about therapy and what they can expect in terms of both practice logistics and the clinical process. They will also want to share appropriate details about their own backgrounds and approach to treatment.

At the same time, providers will need to use time during the initial session to complete a diagnostic interview so they can make treatment recommendations to the client. It can be helpful to inform the client that in the first session, you will be gathering information in a structured, interview-like format, and that what they experience in subsequent sessions may look and feel different. It can be helpful to provide information about what they might expect from a “typical” therapy session.

As you gather information from the client, you'll be assessing whether your specialties and expertise align with their needs, goals, and expectations. If the relationship doesn’t seem like a fit, you can share your perceptions of what type of treatment would be the best match for the needs, and reassure them that you will support them in connecting with a different provider.

Finally, it is important to leave time at the end of what will likely be a very full session for time to allow the potential clients to ask questions about you or your approach to treatment. While providers have personal preferences and philosophies about the use of self-disclosure as a part of the treatment process, this is a time when it can be very helpful to allow your client to develop initial impressions of who you are, how you work, and what matters most to you about the work you do.

Share advice on dealing with vulnerability hangovers

First coined by Dr. Brené Brown, vulnerability hangovers are commonly defined as the emotional state of discomfort, shame, fear, and self-doubt that occurs after sharing personal thoughts, feelings, experiences, or taking on an emotional risk.

In short, it’s the aftereffects that come with feeling vulnerable, and drawing attention to this can help clients be proactive in understanding any feelings that may arise after a session - especially at the start of a therapeutic relationship where adequate trust hasn’t been built yet.

Try sharing the advice of practicing self-compassion and urge clients to be gentle with themselves. Change their perspective and let them know that they should be proud of their bravery to explore their truth.

After the first therapy session

Send a follow-up email regarding any workbooks/assets that may be helpful

After the initial session, you may wish to send an email recommending resources such as readings and workbooks to clients. You may also wish to provide psychoeducation about the therapeutic modality you practice to help orient the client to how you approach the process of therapy, and how you think about psychological change and growth.

Decide on a healthy cadence

Therapy is a highly personal experience, and the cadence of sessions should depend on each client’s goals and/or the acuity of their symptoms, in addition to the financial commitments they are able to invest in treatment.

Initially, it may be best to recommend a cadence of every week or every other week to allow you to build alliance and gain traction towards the clients’ therapeutic goals. It’s important not to have too much time between sessions, as it may be harder to make progress this way.

Don’t be discouraged if a client doesn’t return

For clients, finding a therapist is like dating. They’ll go on many first meetings to decide whether or not they feel like the clinician “gets” them. And if they think it’s a good fit, they’ll move forward with scheduling more sessions.

Clients may also decide that therapy isn’t the right choice for them at this time. While it can be easy to see this as a negative reflection on your abilities as a clinician, it can be healthy to maintain a balanced perspective that includes an awareness of the many factors that contribute to a client’s decision in terms of selecting a therapist.

Closing thoughts

The first therapy session presents multiple opportunities to build a healthy therapeutic relationship with your client, and to set the stage for their future growth and change. By providing a flexible framework for the initial session, you will maximize the opportunity to build a strong foundation for a productive relationship.

References

Wosket, V. (2016) The Therapeutic Use of Self: Counseling practice, research and supervision. 2nd ed. Oxon: Routledge.