How prepared were you for you first therapy session?

[LucidMind]

I'm about to see my first therapy client and I am pretty damn nervous to say the least. How do you know when you are ready to start conducting therapy? Did you all "feel" ready when you began doing therapy?

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[erg923]

No, I wasn't. Hopefully you have some live supervision via mirror or videotape or something? I think this is a relatively new NCSPP requirement, is it not?

And you're ready when they tell you you're ready. I suppose that's the first day of your first practicum, huh? Lol

 

[PsychBoxe]

I did not feel ready. I felt prepared (e.g. acclimated to the setting, supported by supervision), but not ready, if that makes any sense. My first clinical contact was with a couple; talk about starting in the deep end. You are supposed to feel unprepared, there are a lot of things going on in the therapeutc encounter. Trust in your training and your ability to learn and grow.

 

[PsyDr]

When all else fails: listen, express interest, and shut up.

 

[PsychBoxe]

I agree with PSYDR. Less is more, less is more. Anxiety will often encourage activity, or a compulsion to "do something," when the space has not yet been co-created.

 

[CheetahGirl]

Something I always found helpful during those initial therapy sessions (and even now with every initial meeting) is being prepared. Arriving few minutes prior, reviewing the chart, having my clipboard/pencil-pen/demographic forms (or not, depending on the clinic) and being 100% present & curious about whoever walks in the therapy room door. When I've done all that, I'm ready to conduct therapy. (Oh! And made sure there's no salad in my teeth. )

 

[463951]

Agree what others have said, and what Cheetah Girl does is very similar to my own process. To the OP, if you were NOT nervous, I would be worried. Good luck.

 

[Therapist4Chnge]

All good advice in here.

For me it helped to be prepared and not be in a rush (as was previously mentioned). I like to orient the person to everything because many times it is the first time in treatment, it also helps me stay organized during the intake. Everyone has their own style, but I typically have an order that I do things, though it took awhile to get down the right order of things.

I like to start with the who/what/where/why/how kind of stuff…who I am, supervision relationship, limits of confidentiality, structure of the first session, and referral question (or what was told to me). As part of my explanation of the first session I explain that it is mostly information gathering and I try and put them at ease because anxiety (on both sides) is pretty common. Make sure to ask one question at a time, provide enough time for them to answer, monitor your body language, notice their behaviors, and when in doubt….pause before you talk/respond because you may miss something if you jump in too quickly. Remember….two ears, one mouth. Use that ratio accordingly.

In regard to explaining treatment, I usually frame it as an ongoing conversation…and then I usually talk about clinical boundaries and limitations, etc. Pts can have many pre-conceived ideas about what might be involved, so I try and make therapy more approachable, while also making sure I have enough time to gather the information I need for my intake.

It can take some time to find your words and flow, but it eventually comes along. Video/Audio taping and direct observation (2 way mirror & ear bud/phone) were initially scary but ultimately a positive experience. I started my prac. administering assessments and doing intakes for assessment, which I think was a bit easier than jumping into therapy. Now it is all I do….and I don't miss therapy one bit.

 

[MCParent]

To the OP, if you were NOT nervous, I would be worried. Good luck.

Trainees who are not nervous about seeing a first patient are a lot more concerning to supervisors than those who are.

 

[Ollie123]

Trainees who are not nervous about seeing a first patient are a lot more concerning to supervisors than those who are.

This.

As for your question...nope, definitely not prepared. Heck, 7 years later I still wouldn't ever say I'm "prepared" because every time I think I am I get thrown a curveball that leaves me unsure how to proceed. Such is the nature of what we do. I've just gotten better at tolerating the discomfort of knowing how unprepared I am and more confident in my ability to cope with whatever curveballs come my way. Early on I would attempt to "over-prepare" trying to plan seemingly every minute of the session, guessing at client responses and building my responses to their responses, etc.. It may have been helpful to think through and was cathartic at the time, but I don't think I ever went more than 10 minutes without having a client say something that off-script that forced me to deviate from my carefully laid plans

Generally, I agree with others above. Show up early...you do NOT want to be rushing over from a meeting and be arriving the minute your session starts! The first session is generally quite simple unless the clinic requires some structured intake procedures. My goals for a first session: 1) Procedural stuff (Clinic Procedures, Consent to treatment, confidentiality rules, release of information, etc.), 2) Establish rapport, 3) Ensure safety (i.e. no SI/HI). Beyond that "Tell me more about what brought you in here" and anything else you accomplish from there is gravy.

Try not to stress, but know that you will and that is okay. We all did.

 

[cara susanna]

I don't think that I really started feeling comfortable doing therapy until my fourth year.

 

[WJPSYCH]

I think my first therapy session was my second week of grad school. Granted, it was co-therapy and I mostly sat and took notes during the intake. I still appreciated getting that first clinical experience on the books so I could answer "yes" if a client asked if I had ever done this before.

 

[bostongal109]

Oh Lordy. I did not feel ready. It took me a few years to feel comfortable with it. The only advice I can give is to sit with the silence, and don't feel pressure to lead the sessions. Don't work harder than the patient and relax, you don't want to transfer that anxiety

 

[Rivi]

Haha, I didn't feel prepared at all. I still feel nervous before sessions. Fortunately, you will get less nervous and also better at being nervous.

 

[G Costanza]

I remember taking comfort in knowing that if my professors thought I was ready, than I was ready. It was hard to have self confidence in something I had never done. So I used their confidence until my own grew over time.

 

[LupaCupcake]

This is not the same thing, BUT....I remember the first time I had to do group therapy as a psychiatric technician. The techs here run the dayrooms, do some groups, deescalate situations etc etc. No it is not the same as invidual therapy with a Psychologist so please do not think I am comparing myself to that level. This is just the closest experience I have. I was sooooo nervous and having a dayroom full of patients staring at you does not help calm those jitters.

I was not trained very well at designing and doing group so I fell back on my limited undergrad education, google and the power of talking to people with experience. I got out many textbooks I held onto and researched my bootie off. I would watch the groups done by therapists/social workers. Over time I built a portfolio with groups organized by focus ie anger, interpersonal skills etc. Eventually, I became strong with groups and helped other techs.

I am not a tech anymore, but I still have to do groups with my new position. I occasionally do a group on self advocacy wince I am the patient advocate.

I still get nervous, but I remind myself that these are people...not just patients with a medical file. They may or may not respond well to the therapy, but ultimately they are looking to me to deliver something useful for them and I need to try my best.

I lost count how many patients have told me they can tell I really care and that is what I remember when I am nervous. The PTS that have hugged me when they left (technically were not supposed to hug cause its considered a hold, but I do), the PTS that really seem to take in the tools we hand them, the ones that have said thank you with a lot of heart. I remember those moments and it fuels me to push pass my own anxiety.

I suppose that means my suggestion is to build memories, as you go along doing therapy remember those memories that will fuel you. Let them remind you that you are doing a good job. Whenever I have been one on one with PTs, which I often do with this job, I have learned to ask open questions that give them multiple routes to go with answering which hopefully yields way for them talking more as I take notes. I also ensure that they know I am paying full attention to them ie ignore your cell phone, don't look disinterested etc. Remember your body language.

 

[smalltownpsych]

I still get a little nervous when seeing a new client and I still remember the anxiety about meeting my first client. I was afraid that they would ask me how long I had been a therapist and how would I answer that one on my very first session!

 

[LucidMind]

Thanks for the good luck wishes! It was great reading about the different experiences you guys have had...it sounds like being nervous and apprehensive is definitely the norm. The first session went surprisingly well, my anxiety died down after I went over the "technical stuff" (confidentiality etc etc). I am trying to follow an ACT manual for anxiety, so it was helpful having a little more structure to go by. Next anxiety provoking situation....going over the tape with the supervisor . Live supervision mirrors/ear bug things or watching from a computer) isn't required, though most supervisors do it now (my current one is really old-school and doesnt).

 

[PsychBiker]

Remember:

http://www.dca.ca.gov/publications/proftherapy.shtml

 

[CheetahGirl]

Ha! PsychBiker, you may have raised this ("professional therapy never includes sex") in jest, but you are completely right in doing so.

Yes, that's why the 'borrowed ego-strength' that G Constanza spoke of, and the 'sitting with silence' that bostongal 109 mentioned are important. You have the time to ask yourself internally "would my supervisor do this? Or how would So & So handle this?" Especially if your client hits on you or you feel a desire to get to know your client outside of therapy.

Ethical obligations are not difficult to uphold as long as you know your own 'stuff' and question any unethical behaviors BEFORE they happen.

Remember:

http://www.dca.ca.gov/publications/proftherapy.shtml

 

[Occlumentia]

I'm a clin psych grad student, been doing therapy for a year now, and I still feel nervous before the first session because of the uncertainty: you often won't know much about the presenting problem before you meet the person, you don't know what they're like interpersonally and how easy it'll be to build rapport, you don't know their circumstances and level of risk and distress, etc.

I deal with this by being prepared. I remind myself about the confidentiality and limits spiel I give at the beginning, I have a prompt sheet with me for conducting the initial assessment (in the case of therapy) or a list of the instruments I plan to use (if it's a cognitive assessment), and I also have emergency info and numbers on me. As someone else said, though, if at a loss, just attend to the person and really listen. One of my supervisors also says that if in doubt, be human.

It also felt odd at first to have my sup watching me live or reviewing the recording later, but it's really useful, and you learn a lot from it. You also learn a lot from watching your own sessions, even without your supervisor.

 

[FLpsychstudent]

I'm about to start seeing clients and I also feel nervous and not prepared! But I think the only way to feel prepared is to see clients and get practice, so I think it's normal. Older students in my program have pretty much all said they felt unprepared when first starting the clinic, but it ended up fine. And yes, I plan to bring in a lot of prepared material/scripts when I first start seeing clients...mostly as a safety aid haha, but overly preparing will probably make me feel better. I'm also trying to keep in mind they are just people wanting some help, and I don't have to know everything! But yeah...it's pretty anxiety-provoking!

 

[smalltownpsych]

I would think the bug in the ear thing would be really distracting for me. I am glad that we never used that methodology. I have used tapes and observation, much less obtrusive IMO.

Another tip, if things feel like they are bogging down a bit, try to take a lighter more conversational stance. Some people aren't ready to delve into the issues right away and getting them to talk about other stuff that they are more comfortable talking about can be crucial in building rapport. I sometimes forget this myself since I have become pretty adept at developing rapport while sticking to the issues and relevant info. What happens is that I'll find the answers shortening up to yes and no and the resistance increasing and I'll remember and shift gears completely to ask something like "what kind of music do you like?" or "seen any good movies lately?"

 

[AcronymAllergy]

I would think the bug in the ear thing would be really distracting for me. I am glad that we never used that methodology. I have used tapes and observation, much less obtrusive IMO.

Another tip, if things feel like they are bogging down a bit, try to take a lighter more conversational stance. Some people aren't ready to delve into the issues right away and getting them to talk about other stuff that they are more comfortable talking about can be crucial in building rapport. I sometimes forget this myself since I have become pretty adept at developing rapport while sticking to the issues and relevant info. What happens is that I'll find the answers shortening up to yes and no and the resistance increasing and I'll remember and shift gears completely to ask something like "what kind of music do you like?" or "seen any good movies lately?"

I go back and forth on bug-in-the-ear. I know it's often used in various kiddo-oriented treatments (at least from what little I know of those), but I wonder if, like you've said, it might not be more distracting than helpful until the individual has a base skillset down. After that, I could potentially see it being quite useful for on-the-spot correction/suggestion (e.g., in MI).

 

[smalltownpsych]

I would be so conscious of it, I don't think that I would be able to focus on providing therapy even at my current level of experience. Of course, I haven't done it so am just speculating. It might be okay when working with kids as there is a much different type of focus and skill set required. In other words, with pre-teens I am observing and interacting much more than listening so I could see myself being able to listen to the bug during that type of therapy.

 

[Dr_lost]

...Don't work harder than the patient and relax, you don't want to transfer that anxiety

I like that advice I'll try to remember that for my first therapy session. I've done therapy before and I was nervous. I can just image what it'll be like sitting in the big leather business chair instead of the love seat.

 

[Occlumentia]

What happens is that I'll find the answers shortening up to yes and no and the resistance increasing and I'll remember and shift gears completely to ask something like "what kind of music do you like?" or "seen any good movies lately?"

Interesting, smalltownpsych, do you think it would be too early to point out the resistance (in a tentative way, of course)?

 

[smalltownpsych]

Interesting, smalltownpsych, do you think it would be too early to point out the resistance (in a tentative way, of course)?

When the resistance is due to lack of rapport or an uncomfortability with therapy itself, yes. Many patients want a real person in the room with them and small talk can be essential for that. This is especially true of adolescents. On the other hand, I usually do call attention to the resistance by saying something like, "you really don't seem to like this much".

 

[CheetahGirl]

Likewise, I usually address the 'resistance' and move on...like, "I see you changed the subject, and that's fine if you're not ready to discuss this now. But, I would like to revisit it later...if that's okay with you." (And it usually has been okay to revisit it when the time (or session content) is more applicable.)

Remember ALL of this is diagnostic, including the content of what is avoided and how the patient 'changes the subject.'

When the resistance is due to lack of rapport or an uncomfortability with therapy itself, yes. Many patients want a real person in the room with them and small talk can be essential for that. This is especially true of adolescents. On the other hand, I usually do call attention to the resistance by saying something like, "you really don't seem to like this much".

 

[SublimeNature]

I was super nervous the first time I saw a client which was in my diagnostic prac. However, I was working with young kids so I felt a little less pressure since they will let you know if you're way off base and tell you flat out if they don't like you and don't want to come back - ha! During my intermediate prac I started working with adults and I was super nervous again because of the different dynamics. Just work on building rapport and you will figure out the rest in due time

 

[deadmau5]

I just booked my first client... coming up in two weeks. Dealing with the anxiety by reading various intro to therapy books.

 

[smalltownpsych]

I just booked my first client... coming up in two weeks. Dealing with the anxiety by reading various intro to therapy books.

I also find that making sure to cover limits of confidentiality and informed consent stuff helps to set the tone, then just ask "so what brings you in here today" and then try not to feel like you have to fix everything or have an answer for everything in the first session. One of my supervisors used to always say to just give them one thing in that first session to hold onto. For most patients it's that feeling of relief that they made the first step to getting help so at end of session, reflect that feeling to them. I also will give many patients one concrete and achievable task to work on after first session.

 

[starsinnight]

I just booked my first client... coming up in two weeks. Dealing with the anxiety by reading various intro to therapy books.

Good advice here that I wish I had read before my first session years ago. Definitely agree with the silence and less is more/not working more than your client. For the first year I always had a worksheet as back-up, just in case.

Some good books for beginning therapists- On Being a Therapist and The Gift of Therapy.

Any advice on the first time being a supervisor? I'm nervous meeting with my first supervisee next week.

 

[smalltownpsych]

Good advice here that I wish I had read before my first session years ago. Definitely agree with the silence and less is more/not working more than your client. For the first year I always had a worksheet as back-up, just in case.

Some good books for beginning therapists- On Being a Therapist and The Gift of Therapy.

Any advice on the first time being a supervisor? I'm nervous meeting with my first supervisee next week.

Even if you are the type to not take notes during therapy session, which I typically don't do other than intake, I find it works best to take notes during session and jot down a key point for each case that you are supervising. Especially pay attention to risk issues and ethical/legal issues. It can be easy to talk about interesting case at length and miss some key points in other cases. Some of what you would focus on and how in depth depends on where the individual is at in their training. A first-year practicum student is going to be a lot different than supervising a post-doc. Also, the first session with supervisees you would want to talk about their training goals and strengths and weaknesses.

 

[WisNeuro]

Just remember, it's pretty hard to make people worse.

 

[Therapist4Chnge]

Any advice on the first time being a supervisor? I'm nervous meeting with my first supervisee next week.

You should know your supervision style. There have been some articles over the years about supervision, though specific citations are not something I have in front of me at the moment. I want to say mid-2000s there was a special issue of the American Psychologist on this....Norcross, maybe?

Personally, I outlined my first supervision meeting to make sure I hit everything I thought was important. This is for someone farther along in training…intern or fellow.

(Not an exhaustive list)
1. Supervision style, how it applies to training, what it looks like on my rotation.
2. Expectations of work…quality, timeframe, process of submitting notes for review.
3. Discuss goals of the supervisee, how they fit expectations of the rotation, etc.
4. Jot down goals, expectations, agree upon supervision time/date, what to do if out/coverage, etc. This doc. is formalized and signed by both parties and filed w. the student's file so everything is clear and up front.
5. I usually provide some references about supervision for the supervisee to read for a future mtg.

Good luck!

 

[Therapist4Chnge]

I was super nervous the first time I saw a client which was in my diagnostic prac.

Starting with a diagnostic pre-practica was *SUCH* a helpful experience for me. I was able to lean on the structure of the intake interview, test protocols, etc. I too started with children (ed. testing), which I found frustrating at times but ultimately less intimidating than working with adults. The two-way mirror, knowing ppl were behind the glass, and working with a challenging population was a bit of a learning curve. I also did research with children that involved a range of different tests…so by the time I got to my first "real" practica I was battle tested. The therapy part was a bit clunkier….but it can get easier with time, mentorship, and practice/study.

 

[deadmau5]

^ I have done 3h diagnostic interviewing in my lab and this has REALLY helped me succeed in my current practicum (first one, primarily assessment based). My supervisors are impressed with my reports and case conceptualization, but it is really 2.5 years of diagnostic interviewing that has helped me get to this point.

As for the first therapy session = I survived! Pt is so nice and willing to work on things. Very motivated. Hurrah! I prepped and organized the topics to discuss and that really helped the flow of the discussion.

 

[ikibah]

I had my first therapy session last week and I was actually surprised about how calm I was about it. It went by super quick and thankfully the conversation just flowed. I was more worried about not being worried.