Studying for the NCE – The Initial Session

Abstract

This paper address issues surrounding the initial family therapy session.   It will begin by discussing common anxieties and expectations of family members in therapy.  There will then be an overview of my own anxieties as a beginning therapist.  The paper concludes with a plan that can help me prepare for my first session with a therapist to address these issues.

As a student therapist, imagining my first one-on-one session with a client is a daunting notion.  Family therapy is significantly more overwhelming, in light of the relationship issues and inherent circular causality.  These anxieties are often coupled with a family members who have divergent expectations, anxieties and concerns.  What follows is an overview of common issues concerning clients when beginning therapy for the first time. 

Client Anxieties & Expectations

Desire For Resolution

Prior to the first session, while family members are waiting to be seen, an array of anxieties are likely to loom in everyone’s mind.  Oftentimes, when families enter therapy it is because problems have become unmanageable and they cannot handle things independently.   The initial anxieties clients’ experiences prior to a session are often related to ongoing turmoil at home.  A desire for resolution is a key expectation that fuels efforts to seek outside help.  Clients’ enter the first session with a lot of hope that a remedy to the turmoil can be uncovered (Patterson, et al, 2010).  Each family member probably has a different take on the underlying issues, which further complicates matters.  Ironing these divergent perspectives in the first session can start as everyone takes time to discuss their take on key issues bring the family to therapy.   During this first session the therapist will need to discuss these issues in order to define therapeutic goals (Patterson, et al, 2010).

Motivation and Resistance

Another observation related to clients’ anxieties pertains to the varied levels of motivation present.  This divergence in motivation amongst family member can be observed at the onset of start therapy regarding a noticeable desire to work through issues.  Some family members will be more resistant to the entire therapy process, which is likely to complicate matters further.   It will be important for the therapist to assess motivation and what stages of change each family member is at (Patterson, et al, 2010, p36).  Motivational interviewing techniques can help with resistance and ambivalence as key barriers to therapy.

Perceptions of Therapy

Past experiences in therapy are likely to further color clients’ expectations prior to the first session.  In fact, as a student therapist, when I share with others my career goals, I have occasionally come across people who claim “they don’t believe in therapy”.  While this can at times be related to negative experiences in therapy, it can also be simply an individual’s desire not to “rehash old issues”.   In reality there are many paths to the same point of resolution that are reflective in temperament-based differences.   Some individuals may be more responsive to therapy than others.  Addressing a client’s believes about therapy will require establishing a connection and attending with administrative issues while discussing any past experiences.

Professional Anxieties & Expectations

Performance anxiety is a huge issue for me as a student therapist.  Family counseling is more anxiety inducing than traditional therapy for me, since I’m now in front of a group of people.   Part of this anxiety is related to the fact that I will bring all my life experiences, biases, perceptions, feelings, and temperament to the table while with clients.  Self-awareness will be key to understand how these factors influence my work as a therapist in individual and family counseling.  My tendency has been address such anxieties by being over-prepared with thorough research.  This can involve taking time to review thorough clients’ medical and psychosocial histories as well as cultural backgrounds can be helpful.  Telephone interviews will be helpful in gaining clarity on the nature of the problem and its underlying complexities.

Finally, I feel its also important to mention that anxiety is part of the learning process with beginning therapists.   The stages of development for beginning therapists are all a part of this process (Patterson, et al, 2010).  This development process includes leaning essential skills, developing a theoretical framework, and self-examination.  As I have experienced them, thus far, they have occurred concurrently.

Putting Clients at Ease

Before Initial Contact

Addressing my own performance anxiety will be an essential preparatory step before I can attend to the client’s expectations and concerns.  This will entail self-awareness, adequate self-care, and an acceptance of anxiety as part of the learning process.   Pre-session telephone interviews, discussed in Patterson, et al, (2010), are also an essential step to addressing client’s expectations and anxieties.   Talking with family members in these pre-session phone calls, can allow the therapist an opportunity to assess these expectations and concerns.  In addition to developing a better understanding of the presenting problems, client expectations can also be discussed.  Based on this information, the therapist engages in some preliminary hypothesizing (Patterson, et al, 2010, p22), on the possible nature of the presenting problems.  This process can help the therapist in developing questions for the first interview that can further clarify matters.

Developing Connections

Patterson, et al, (2010) describe joining as a means to make “clients feel a sense of connectedness, which usually arises when they feel you understand, respect, and care about them” (p25).   Joining begins when you shake a clients’ hands and greet them in the waiting room.  It continues when you engage in some preliminary small talk before “getting down to business”.  The main goal of this social talk is to create a safe and secure environment that makes the clients feel at ease (Patterson, et al, 2010).  As the first session progresses, attentive listening skills and direct eye contact will also facilitate the joining process (Patterson, et al, 2010).

Administrative Issues

Confidentiality Issues, Fee Structures, and Release of Information Forms are just a few administrative tasks that should also be addressed during the first session (Patterson, et al, 2010).  These administrative issues, can address several of the client’s concerns about entering into therapy.  Common concerns for most clients entering therapy involve cost and how confidential information will be handled.  Discussing your fee structure and the client’s insurance policy can address cost-related issues (Patterson, et al, 2010).   Limits of confidentiality and how you handle confidential information amongst family members can also ease clients’ anxieties.  The main goal of this discussion is to dispel any anxieties, by making the client aware of what they can expect in therapy.

Defining Goals

Clarifying everyone’s expectations and goals for therapy will involve continuing the discussion that began in earlier phone interviews.   The preliminary hypothesizing that occurs after the initial phone interviews can provide guidance on the questions the therapist must ask.  Taking time to allow each family member to discuss his or her concerns is critical.   There are liable to be multiple problem areas with divergent perspectives on each issue.  Expectations may be unrealistic, the issues unclear, and occasionally some family members may have unstated agendas (Patterson, et al, 2010).  Several key concerns guide this discussion.  Firstly, are the client’s presenting problems within the scope of our care and ability (Patterson, et al, 2010)?  Secondly, do you have a clear understanding of the client’s expectations and can everyone come to a consensus about the goals for therapy (Patterson, et al, 2010)?

Building Motivation

In the pre-session phone interview, it will be possible to assess levels of resistance in family members and determine how willing they will be to participate.  These initial insights can be further explored during therapy through motivational interviewing techniques.  Clients’ should be assessed in terms of their level of resistance against the stages of change (Patterson, et al, 2010).  Motivational interviewing techniques can be helpful in addressing any ambivalence to the possibility of change (Patterson, et al, 2010).

References

Patterson, J., Williams, L, Edwards, T., Chamow, L. & Grauf-Grounds, C. (2009). Essential Skills in Family Therapy: From the First Interview to Termination. New York: Guilford Press.

 

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