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Conducting the First Therapy Session

When You Don’t Know That a Client Will Return for a Second


Windy Dryden PhD


How good do you think counsellors and psychotherapists are at predicting the future? Probably as good (or as bad) as any other group of professionals. And yet we often practise our craft on the assumption that we know various things for certain, when we don’t. For example, let’s suppose that you have a new referral. You greet the person, collect some basic biographical information and invite then to begin by telling you what they hope to gain from seeing you. What they tell you encourages you that you can help them so you continue by taking a case history and perhaps begin to carry out a case formulation. You adopt this stance because you are sure that the client will come back to see you and engage in a process of therapy over time.

Having made this assumption, you have learned from your training that it is not wise to begin therapy in earnest without having a good idea of what you are dealing with. And a sensitively carried out case formulation will give you the necessary data. You may also think that it is not wise to begin therapy without using a classificatory system such as the DSM-V or ICD-10 to help you diagnose your new client’s problems. Doing so will help to determine which ‘treatment’ to use with the client. 

At the end of the session you are encouraged with the start you and your new client have made and you look forward to the next session. However, your client cancels their second appointment with you and does not make another one. You are confused and maybe even a little self-critical for you pride yourself in being a good therapist and have a client ‘drop out’ of therapy after the first session threatens that self-view. 

First, of all your assumption may be quite incorrect. Your client may not have ‘dropped-out’ of therapy. They may have found the first session with you quite helpful and took away something that led them to decide that they could proceed without further professional help. International data show that in public and charitable therapy agencies the modal number of sessions (i.e. the most frequently occurring number) clients have is ‘1’, followed by ‘2’, followed by ‘3’ etc. Now you may be thinking that this figure proves that the therapy they received was not very good and you are right in 20%-30% of cases. However, 70%-80% of clients having a single session of therapy are satisfied with the help that they received (Talmon, 1990; Hoyt &Talmon, 2014; Hoyt, Bobele, Slive, Young & Talmon, 2018). How do we know who will come for one session and who will attend for more? The answer is that we don’t. And how do we know who will benefit from a single session and who will not? The only reliable why of doing so is to give the client a single session and to see if they benefit from it. 

All we know for certain as therapists is that the client is with us now. They may return and they may not. Given this fact, I pose the following question: How should we conduct the first therapy session when we do not know for certain if the client will return for a second? I will answer this question informed by the literature on single-session therapy. 

1.    Invite the client to work with you to help them as much as you can in the first session while stressing that further help is available should they need it.

2.    Begin therapy immediately 

3.    Invite the client to select their most pressing concern for which they would like help and strive to understand it from the client’s perspective. 

4.    Elicit what the client wants to achieve from the session and work with them to achieve this goal.

5.    Create a focus for the session and maintain this focus throughout 

6.    Discover what the client has previously done to solve their problem. Encourage them to use what was helpful and to discard what was not.

7.    Identify how the client has unwittingly maintained their problem and consider that the opposite of this may help them solve their problem.

8.    Discover the client’s strengths and encourage their use, if appropriate.

9.    Discover the client’s external resources and encourage their use, again if appropriate.

10.    Adopt a solution focus and help the client to identify the best solution that they can based on all the above factors.

11.    If possible, have the client rehearse the solution in the session and make suitable adjustments to that solution or select a different solution.

12.    Help the client to develop an action plan to implement the decided upon solution.

13.    Identify and problem-solve relevant obstacles to change. 

14.    Ask the client to summarise the session (rather than you doing so) and encourage them to identify relevant ‘takeaways’.

15.    Encourage the client to think how they may be able to apply what they learned to other problems that they may have in addition to their nominated problem. 

16.    Bring the session to a suitable close where the client leaves the session with a sense of hope, if possible. 

17.    Remind the client that further help is available should they need it and if necessary encourage them to reflect on what they learned from the session, digest this learning, take appropriate action and see what happens before deciding to make another appointment. I call this the ‘reflect-digest-act-wait-decide’ process (Dryden, 2020).

18.    Arrange a suitable time for a follow-up session.

Those of you in private practice may be thinking, ‘This is all very well, but how will I 

earn a living if I adopt this way of working?’ My answer is as follows. First, about 50% of clients will not require further help from you after the single session which means that 50% will. Second, the clients in the first group will go away satisfied and recommend you to their family, friends and colleagues as a therapist who gets down to the business of helping people quickly. After all, isn’t this why we came into the profession to offer prompt help to people at the point of need? 


References 


Dryden, W. (2020). The Single-Session Counselling Primer: Principles and Practice. Monmouth: PCCS Books. 

Hoyt, M.F., Bobele, M., Slive, A., Young, J., & Talmon, M. (2018). (Eds.), Single- Session Therapy by Walk-In or Appointment: Administrative, Clinical, and Supervisory Aspects of One-at-a-Time Services . New York: Routledge.        

Hoyt, M.F., & Talmon, M.F. (2014). What the literature says: An annotated bibliography. In M.F. Hoyt & M. Talmon (Eds.), Capturing the Moment: Single Session Therapy and Walk-in Services. Bethel, CT: Crown House Publishing.

Talmon, M. (1990). Single Session Therapy: Maximising the Effect of the First (and Often Only) Therapeutic Encounter. San Francisco: Jossey-Bass.

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