Shirah Vollmer MD

The Musings of Dr. Vollmer

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.


6 Responses to “The First Session”

  1. Jon said

    How to have a first session? That is a hard question. Be it physiotherapy from either the therapist or patient point of view, or just interacting with another person, there are two sections of the dialogue early in the embedded video with Dr. Yalom that resonate well with me.

    “To show more of my uncertainty to the patient…. Being uncertain is a large part of physiotherapy; it is a large part of life. And it is something that is quite uncomfortable…” This becoming comfortable with the uncomfortable uncertainty of life is one of the keys to making progress.

    “For us to be allies together in the therapeutic venture… Equal partnership in a therapeutic alliance … Equal in that we are both exploring together.” Allies forming a team tend to make stronger and deeper inroads into problems.

    Also, thank you for the introduction of the wonderful word, alexithymic. It was not within my ken, but now is.

    • Yes, uncertainty is perhaps the hardest thing for my residents to learn, in that with years of education, many of them expected more, not less, certainty. Although, thinking back to my college days, “the bigger the island of knowledge, the larger the sea of wonder,” was one of my favorite quotes. Now, I need to track down the author. Thanks.

  2. Shelly said

    Yes, I agree with Jon, I had to look up the word “alexithymic,” and it is a very valuable word to know! At a first session, if the therapist asked the patient, “How can I help you?” I think the patient would be terrified! The patient came to the therapist in distress and doesn’t know what he or she needs. He just knows he needs help to feel better, to sort out his life issues; by asking this open-ended question, it relays (at least to me) uncertainty, exactly what the patient doesn’t want to hear. Another question that begs a very short answer is, “Who cares about you?” The patient can list certain family members and friends, and that’s that. What did that question serve, to the budding therapist? I would think that in the first session or two, the therapist would outline a sort of workplan of the journey the patient and therapist would take together. Is that not a realistic expectation?

    • Yes, outlining a work plan is not completely realistic. The journey is a changing, and unforeseen journey, with the hope of diminishing symptoms through greater insight into the origins of one’s troubles. The spontaneity of the discussion is key to searching for underlying motivation and internal obstacles to happiness. The question “who cares about you?” is designed to explore the emotional landscape in the patient’s life. I find this question rather captivating because the variability in answers is enormous. Who gets listed first? Parents, siblings, spouse, children, friends, mentors, etc. Maybe the patient feels no one “really” cares, or maybe they feel people care about them because they are supposed to, and not because they actually feel the caring. This question allows me to enter into the subjectivity of the patient rather quickly without making the patient feel threatened or exceedingly vulnerable. Thanks.

  3. ralphhh2 said

    Excellent post and comments!!! It is nice to see both Karen Horney and Irvin Yalom in the same blog.

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