What happens in the first counseling session?
Initial Assessment Session
The first session, usually called an ‘intake’, will go a little different than other sessions.
Each therapist or agency does it a little differently, but in general, the goals of the intake session are that by the end of the session you and the therapist will get to know each other a little bit and have a better sense of if it feels like a good fit, you will have shared some issues that have brought you to therapy, and you two will come up with a goal that you are working towards together.
Confidentiality
When I’m meeting with a client for the first time, I’ll always begin the session by sharing with them the privileges of confidentiality: that I’m ethically bound to keep everything you say just between the two of us, that all my notes go in a super safe password protected health record system, and that your confidentiality is taken so so seriously that I won’t even acknowledge I know you if we see each other in public, unless you want to say hi to me first. I also explicitly share the limits of confidentiality: that if you are a grave threat to harming yourself I have to tell someone, if you are about to harm someone else I have to tell someone, if there is child or elder abuse going on I have to tell someone, and if I get a court order I may have to reveal some or all of my notes.
I try to get the confidentiality discussion out of the way right away so that people know both that they can trust me, but also so that they’re also informed and aware of what the limitations of confidentiality are if it comes up in the first session.
I give people a chance to ask if they have any questions at all about confidentiality. Probably about 90% of people don’t have any questions at all and we keep rolling, and then about 10% ask for more detail about what it means if they’re a harm to themselves, at which point I just explain to them a little more about what goes into my assessment of if we need to bring someone else into the conversation because the risk of them harming themselves is significant. It’s totally normal and okay to have suicidal thoughts. You can bring that up and we can talk about it. But - if we think you’re really likely to act on those thoughts in the time between when our session ends and I see you again, we may have to bring in someone else to help assess the situation.
Initial Questions
Then the two of us usually talk together about what therapy has been like for them in the past if they’ve done counseling before (what they have liked and what they didn’t like), and I share a little bit about myself and my own style, which pulls from a variety of orientations, but leans heavily on Internal Family Systems (IFS).
After that, I ask clients a bunch of questions and get to know them a little better and find out what brought them to therapy. We don’t go too deep or usually spend too much time around a single topic the first session, it’s just a chance for you to share all about you, and for me to get an overall impression or understanding of what’s going on in your life.
I’ll ask them about education, work, family, relationships, alcohol and drug use, suicidal thoughts, what’s not going well, but also what is going well and what supports you have and things you’re doing that are working well for them right now.
Anxiety and Depression Assessments
I will always ask specific questions about anxiety and depression symptoms.
I’ve found that if I don’t ask concretely about symptoms, and just asked broadly if someone felt anxious or depressed, we might miss something.
Sometimes people say they don’t think they are feeling anxious at all, but then when I asked them about symptoms, suddenly it would turn out they’ve had every single one of the symptoms of anxiety and score highly for Severe Anxiety!
All of that just really helps me to get an initial first impression of what’s happening and a) helps me to form a diagnosis (which I’ll usually discuss with the client), and b) helps me to determine if I think we’d be a good match and there is a high probability that I’d be able to help you.
If I’m not a good fit - I’ll point you in the direction of someone who I know will be able to help you.
Then, I always wrap up the first session with a few closing questions:
Closing Questions
First, I ask what it’s been like to be with me this session and how it felt to be with a white male therapist in his 30’s. Sometimes people will answer quickly and we move on, but, sometimes it really opens up a lot of talk about our intersecting identities.
Our identities do affect the relationship in some way, and so, it’s great to be able to talk about that initially…but also hopefully it lets you know that we can continue to talk about that as we develop a deeper relationship.
For example, some older adults may admit that I remind them of their son, or, some men may say they’ve only seen female therapists in the past and they are kind of nervous about being vulnerable with a male therapist and aren’t sure what to expect. LGBTQ+ clients may voice initial concerns about me judging them, and a client of a marginalized racial group like an African American client may ask about whether they think I could really understand their experience as a Black person in America. All of these are great conversations to have in the first session, and to continue having as therapy progresses. How we interact with each other can be, in a lot of ways, a micro example of how you interact with others in the world.
Second, I ask you if you have any questions for me.
And then third, I always ask, “an hour from now when you’re at home thinking back on the session…is there anything that you’ll think you wish you had said to me?”. Sometimes there’s nothing, but sometimes it can open up a conversation about something really important that otherwise would be left unsaid.
Next Steps…
Finally, if I think we could be a good fit, I recommend that we both find a time for a second session, and I let you know that I’m excited about the possibility of working with you and getting to know you more. But, I would also tell you that if over the next week you decide it’s not the right fit, just to shoot me a text or email and let me know. For a lot of people, it’s more comfortable to schedule something in the books and then cancel over text or email than feel the pressure and potential awkwardness of telling me to my face that you don’t want to work with me. I mean, I’m totally okay with you telling me that, but, I don’t want to put you in that position if that sounds uncomfortable, so I always tell people to just cancel later if it feels better.
That’s pretty much it!
Again, every counselor is a little different, but, that’s the flow of my own intake sessions, and, I think that’s probably pretty close to the way most therapists do theirs as well.
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