The room hums with a nervous energy. A half-dozen psychiatry residents sit around the table, questions bouncing back and forth between us. Will you shake hands? Introduce yourself by your first name? Your last? What will be your opening question? “What brings you in?” seems to gain consensus as a safe way to start, but then what? Will you hold a notepad? Actually take notes? Start with their childhood, or their present problems? Do you try to define their goals in the first session or save this for later? And where do you stick that brief spiel about confidentiality and safety?
Having spent over a year on the inpatient psychiatric ward, we are each now embarking into the world of outpatient psychotherapy, the bread and butter for most therapists. Our first therapy patients — blissfully unaware that they are our first — sit out in the waiting room. I imagine they, too, are filled with their own anxiety, wondering what we will be like, whether we will be cold or approachable, easy to talk to or difficult, and, most important, whether we can help.
While as junior clinicians my fellow residents and I probably had a disproportionate amount of angst regarding our patients’ (and our own) first therapy session, experienced practitioners recognize the importance of the first session, too. It’s important for laying the foundation for sessions to follow — and, in fact, it can determine whether there will even be a session to follow.
In his latest book, The Art of the First Session: Making Psychotherapy Count From the Start, clinician and author Robert Taibbi offers us an opportunity to think about what goes on in the first session and how to make the most of this important encounter. In his forty years of experience working in community mental health with couples and families, Taibbi, a licensed clinical social worker, has done many, many first sessions and distills this experience into his book.
Taibbi is upfront about the new challenges facing clinicians today. Patients often come armed with googled research regarding their problems and are likely to know as much as the web has to offer about the clinician they are coming to see. “With that knowledge,” he writes, “comes another big change in client expectations. Even if she hadn’t been in therapy before, now having done her homework, watched YouTube videos or picked up tidbits of what to expect from her sister who has been in therapy, [the client] has a pretty clear idea of what she wants.”
Furthermore, what the client expects in the first session may diverge from what the clinician was planning to offer. Our era of instant gratification, Taibbi writes, “combined with insurance companies and mental health centers capping their sessions to reduce costs or waiting lists, most clients are expecting to skip your three-session assessment model and are ready to hit the ground running.”
Rather than focus on the content of the first session (there are plenty of books on that), like a skilled therapist, Taibbi turns attention to the process. “Tracking the process — the ability to stay in lockstep with the client all through the session — is an essential skill and particularly one that less experienced clinicians can easily lose sight of,” he writes, adding, “Like the clients themselves, new clinicians can get mired the swamp of content.”
Guilty as charged.
It is easy to sit through that first session and wonder, Where are we going here? Who is steering this ship? Taibbi uses the first four chapters to focus on individual therapy. The first chapter, for example, breaks down a series of skills, including such things as tracking the process, changing the emotional climate, and anticipating transference issues. Other chapters focus on structuring the first session and what to do when things go awry — a chapter I found particularly relevant in addressing some of my own private anxieties. Taibbi then shifts to couples and family sessions, with their own set of challenges, and then ends with a chapter on how to move forward from that first encounter to future sessions.
The book is highly readable, written in a casual style and sprinkled with vignettes and humor. Taibbi’s examples ring true, and are clearly pulled from his extensive experience. I found myself looking forward to discovering the next chapter and thinking frequently, Ah, exactly, or, Oh, I’m definitely trying that next time.
The Art of the First Session: Making Psychotherapy Count From the Start
W. W. Norton & Company, February 2016
Hardcover, 240 pages