Goals for the first session

As a therapist, I usually reserve the first therapy session with a new patient to focus on a few important points of development.

– To learn why the patient is coming in for treatment.

– To develop treatment goals for the course of therapy.

– To establish a positive working relationship with the patient.

As you may notice, there is little in the way of therapeutic change that comes from the first session. I believe that prior to engaging in active skills in therapy, it is important to build a therapeutic space and relationship that is conducive to change. Moreover, it is important to establish what changes the patients wants to see first based on their goals for treatment. It is not my place to determine that for the patient.

To address each of the three goals above, there are specific questions that I find can be immensely helpful to setting the foundation for the course of therapy. I discuss these questions in the sections below.

Questions to learn why the patient is coming in for treatment

1. What made you decide to seek treatment now?

This question helps us to understand the current life events that led someone to be seeking treatment at this very moment. This information may begin developing a narrative of a patient’s history and presenting problems.

Additionally, allowing the patient to discuss their decision to seek therapy may reaffirm their resolve to engage in treatment and adhere to recommendations.

2. Have you had past treatment for this problem before?

Querying past treatment can be helpful in getting a sense of the patient’s experience with different treatments and baseline knowledge of the specific treatment modality (e.g., cognitive behavioural therapy).

Perhaps more importantly, this question allows us to understand what went well and what did not go well in treatment for those who have received prior treatment for their problem. We can therefore learn from the successes and mistakes of our therapeutic predecessors.

For example, perhaps the past therapist was not letting the patient set their own goals and spent more time providing psychoeducation and following the treatment protocol rather than listening to the wishes of the patient. Or there may be specific skills that the patient really resonated with and enjoy using in therapy. These are great lines of data to follow to ensure that we are setting therapy for success.

Questions to learn about the patient’s goals

1. What do you hope to get out of treatment?

The simplest question is often the most effective question. Asking a patient what they hope to get out of treatment can be helpful to start formulating ideas on how to develop specific goals for therapy that is based on the patient’s own wishes and hopes.

For example, the patient being treated for anxiety might report wanting treatment to make them feel less stressed on a day to day; to feel confident enough to start their job again; and be able to enjoy life again.

2. If this treatment worked, what would you be doing differently?

The question before is great at getting a sense of potential patient goals. However, some of these goals may be a bit vague to adequately operationalize in therapy.

For example, let’s say a person in therapy for their insomnia says that “they want to sleep better” and “feel better throughout the day” after treatment. For a cognitive behavioural therapist, this can be tricky because sleeping better and feeling better can be different for everybody.

Therefore, asking the patient what would be different can be helpful to developing actionable goals to achieve. For example, a patient may consider sleeping/feeling better as “falling asleep within 10 minutes on average” or “being able to take a walk in the morning”. These are much more actionable goals in treatment (also known as SMART Goals).

Questions to develop a positive working relationship

1. Why is making this change important to you?

This question can be a fantastic addition to the first session because it allows us to understand the patient’s values. That is, what is important in the person’s life that makes them want to change at this time?

For instance, the person with sleep problems may want to change because they want to feel more engaged in their social life and be more productive at work. Therefore, relationships and work are two values that support this person in working hard throughout treatment.

Asking this question may also increase the working relationship by emphasizing the patient’s resilience and focusing on important positive areas of the patient’s life that they want to work on.

2. Is there any feedback you have for me for how today’s session went?

Eliciting feedback from the patient is a great way to showcase that therapy is collaborative and you are focused on their well-being. This can often be a great way to build rapport and patients are generally appreciative that you are being human and willing to learn.

Moreover, this is a chance for the patient to reinforce the great work you are doing and to provide information on specific needs they may have for treatment!

Beyond specific questions, there are also different types of listening skills that can be helpful to build rapport.

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Best wishes,