The First Session
Posted by Dr. Vollmer on June 10, 2013
In order to begin to become a psychotherapist, one needs a theoretical model. This model requires intensive readings about human behavior and human motivation; readings not often discussed or assigned to psychiatric residents. Yet, even if readings were assigned, there is no consensus as to what literature should be read. There needs to develop a pluralism of views, so that the commonality of the models can be understood. Reflecting the patient’s communication, a “Rogerian reflection” requires the budding therapist to learn to listen and reflect, in addition to listening and evaluating. The parallel process between a diagnostic evaluation and a “first session” mandates that from the patient’s perspective, the therapist “heard them,” whereas from a colleague perspective, the physician can summarize the patient, being able to present a diagnostic formulation, an idea about how the patient landed in his office. The other parallel process is that of listening and feeling. The patient is presenting a history, along with exuding feelings, or not. The connection between the story and the feelings can vary from articulate to alexithymic. Many times, the first session allows the therapist to clarify. For example, patients often use the the word “upset” but more specifically they feel scared. “Yes, but how do I begin?” I imagine the student to ask. “How can I help you?” is always available to you, I will respond. The goal is to get the patient to talk about his expectations and the meaning to him that he has stepped into your office. The first session is an opportunity to think about what is the next step. It is not a commitment to jump into psychotherapy. The line between assessment and treatment blurs, but at least in the beginning, the therapist can attempt to make the distinction. Likewise, the patient is evaluating the therapist at the same time that he is revealing his distress. The patient then has the anxiety of seeking help, the anxiety of his presenting problem and the anxiety about the fit between the therapist and himself. These multiple issues must be addressed in the first session. Like a first date, if the anxiety goes too high, the journey will end abruptly. “Who cares about you?” is another opening question, an attempt to understand the emotional landscape. Understanding work and play come next. “The human being has an inbuilt propensity toward self-realization,” Karen Horney said in her book “Neurosis and Human Growth”. Our job, as Irvin Yalom says, is to help the patient get out of his own way.