Therapists, especially student clinicians and those at an earlier stage of their career, can often feel disoriented about what the first session of therapy should look like.

In particular, they may experience a lot of pressure to make the session worthwhile for patients and feel compelled to resolve their problems by the end of the session.

Although that outlook is very compassionate to the patient, it’s definitely not the expectation junior clinicians (or any clinician – for that matter) need to have in mind, nor it is necessarily beneficial to the client. Because when we’re in a rush to solve the problem, we might end up losing the patient along the way. Trust and understanding need to be first established before active therapeutic skills should be employed.

The article gives some tips and insights on how you might want to spend the first session in a way that keeps in mind the patient and relieves pressure on yourself to try and cure 20 years of depression in a 60-minute session (spoiler alert: you won’t – and that’s okay!).   

Goals for first session

There are a few goals that I like to keep in mind for the first session to best support the well-being of the patient.

First, I briefly introduce myself, go over housekeeping (e.g., consent, limits to confidentiality), and provide some expectations on treatment. This helps the patient to learn more about me and gear the patient towards taking ownership of the treatment. Therapy is not like medication – what you put into it is what you get out of it (i.e., home practice and regular attendance are very important!).

A second goal is to begin establishing a therapeutic alliance with the patient. Showing empathy through active listening and statements that accurately reflect the patient’s experience can go a long way to developing positive rapport. The patient will feel heard and consider you as a competent clinician who really understands their problems.

A third related goal is to start learning more about the patient’s presenting problem and obtaining relevant information that is helpful to support developing hypotheses (i.e., case conceptualization). For example, you may start considering how certain thoughts, behaviours, or other patterns might be contributing to the person’s problems. You don’t have to act on it yet, but getting this data will be useful down the road.

My last goal is to start working with the patient to develop specific and actionable SMART Goals that they hope to get out of treatment. This process is very collaborative and you should check with the patient to determine if achieving these set goals would make them feel that therapy was a success.

Components of the first session

1. Introductions (2-3 minutes)

2. Housekeeping and expectations (5-10 minutes)

3. Exploration and active listening (20-30 minutes)

4. Sharing CBT model and psychoeducation about the disorder (10-15 minutes)

5. Establish goals (5-10 minutes)

6. Ask for feedback (5 minutes)

I would say if you can touch on most of these components, you are in excellent shape for the first session.

You can see that there are no hints of active therapeutic change (e.g., Socratic questioning or thought records) in the first session because the goal is to really explore and understand the challenges that the patient is coming into therapy with. The first session is a time for building rapport and understanding, and showing that therapy is a safe and collaborative space.

Final Tips

Don’t put too much pressure on yourself! If you go into the session with an open and empathetic mind, genuinely wanting to learn more about the patient, you are going to do just fine.

Remember that both of you bring expertise to the table – the patient is the expert of themselves and you are the expert in treating the psychological problems that they are experiencing.

Therapy is a collaborative space and you should not feel that you have to ‘save’ the patient. Your role is to provide the expertise needed to bring the patient closer to their goals, but the patient must take responsibility and ownership of the therapy as well to truly improve.

Best wishes,