First Session Screening for Therapy Suitability In the initial contact with a potential patient, it is essential to quickly assess if the individual is a suitable fit for outpatient therapy. Factors to consider include whether the patient’s needs align with psychotherapy, if they can afford the services, and if their condition is appropriate for outpatient treatment. It is crucial not to portray the first session as the beginning of therapy to manage expectations effectively. Transcript: Speaker 1 So when I get that first phone call or email, I just want to get the most general idea of is this even a reasonable fit for an outpatient setting for a private practice setting. And I don’t want to get too much into details. I want to know that they can pay my fee or they have insurance that I work with. I want to know that what they’re coming for is generally in the ballpark of something suitable for psychotherapy. If they tell me they’re schizophrenic or just coming out of an inpatient hospitalization and that’s their diagnosis, they’re probably not going to be a suitable patient for a from My practice, at least not on an outpatient basis. So I just want the just the roughest idea. Does this sound suitable for therapy? Can they afford to be in my practice? And so this is really important. The first session is never the start of therapy. And you should never frame it to a prospective patient so that they think that the first session is the start of therapy. (Time 0:04:00)
Initial Consultation for Therapy When considering potential patients for therapy, it’s important to gather enough information in the initial consultation to assess if they are suitable and can afford the treatment. The first session should be framed as a consultation rather than the beginning of therapy, as it may take multiple sessions to make a realistic assessment of how to help the patient. Transcript: Speaker 1 If they tell me they’re schizophrenic or just coming out of an inpatient hospitalization and that’s their diagnosis, they’re probably not going to be a suitable patient for a from My practice, at least not on an outpatient basis. So I just want the just the roughest idea. Does this sound suitable for therapy? Can they afford to be in my practice? And so this is really important. The first session is never the start of therapy. And you should never frame it to a prospective patient so that they think that the first session is the start of therapy. The first session is a consultation and actually it may take more than one session. And the purpose and this is what I this is, to answer your specific question, what do I tell the patient on the phone or by email? The purpose of this first consultation is for me to find out what kind of help they’re looking for to get to know enough about them to make a realistic assessment of whether I think I can Help and for (Time 0:04:36)
Building Therapeutic Relationship Takes Time The effectiveness of therapy sessions varies based on the patient’s level of functioning, with healthy neurotic individuals potentially benefitting from single sessions, while those with character pathology may require longer-term therapy. The first session is not the start of therapy, but an opportunity for the therapist to assess if they can help, and for the patient to decide if they want to work with the therapist. Building a therapeutic relationship requires time and multiple sessions may be needed to establish this connection. Transcript: Speaker 1 Are you making? All of the above. And I want to emphasize, if the patient is relatively healthy functioning, what we call in the psychoanalytic world, the healthy neurotic level of functioning, then you’re likely Going to be able to do it in a session. As you move into character pathology range, it’s very unlikely that you’re going to be able to do it in a single session. It’s going to take longer to know the things that you need to know and see if you can get on the same page with the patient about what the purpose of this work is. So I can’t, it’s so easy to say, I can’t emphasize this enough because so few people do it. The first session is not the start of therapy. The first session is for me to get to know them well enough to make an informed, you know, offer an informed professional opinion, you know, recommendation about whether I can help and For them to get me to know me well enough to decide if they even want to work with me, assuming that I think that psychotherapy with me could help. So we tell the perspective of patient, you know, our first meetings, you know, maybe one meeting, maybe several can’t know in advance. (Time 0:06:47)
Understanding Clinician Comfort Zones Clinicians need to identify the type of patients they are comfortable working with, as this varies for each individual. Some thrive on working with high-intensity cases, while others prefer working with only one such patient. It is crucial for clinicians to know themselves and their limits to ensure a successful treatment relationship. Putting patients’ needs ahead of their own can lead to trouble, emphasizing the importance of a treatment relationship that benefits both parties. Transcript: Speaker 1 So you may be comfortable with a different range of people than I am, but the point is every single clinician needs to understand, what am I comfortable working with? And that’s going to be different for every clinician. Some people thrive on working with multiple patients in their practice with borderline personality, you know, organization where there’s a lot of drama, intensity, chaos. Some people love that. Most clinicians don’t. There’s kind of a rule of thumb, you know, like one patient in that level of functioning is probably, you know, is probably all that most clinicians can reasonably do a good job with, But you need to know, you need to know yourself as a clinician that comes with experience. So one thing that’s implicit in what I’m saying is this is a two way street. A lot of, I see a lot of younger therapists feel, you know, very responsible, you know, they’re sort of caretakers and help givers and they feel very responsible to, you know, try to take Care of the patient. And what they end up doing is, you know, putting the patients needs ahead of their own. And it’s a recipe for trouble. A treatment relationship has to work for two people where it works for no one. (Time 0:10:40)
Treatment Frame in Psychotherapy The treatment frame in psychotherapy includes arrangements such as privacy, confidentiality, meeting schedule, fees, and policies. These elements create the conditions necessary for therapy to occur, although they are not the therapy itself. In psychodynamic therapy, aimed at self-understanding and psychological change, consistent meetings and sufficient frequency are vital for the therapeutic process. The therapist’s goal is not just symptom management but facilitating personal change, which requires more frequent sessions to be effective. Transcript: Speaker 1 I would rather work with it in the treatment than, you know, yeah. So we’re talking about the treatment frame and the treatment frame is basically what are all of the arrangements that we make with our patients that make it possible to do this work? And you know, the treatment frame is things like, you know, a consistent, well, privacy and confidentiality, a consistent, you know, predictable meeting schedule. The agreed on fee, your policies regarding, you know, Mr. Canceled appointments, right? All of this isn’t the work of the therapy itself, right? I mean, part of the frame is we do therapy in therapy sessions and not outside of therapy sessions. All of these things are not the therapy itself, but they’re the conditions that make it possible to do therapy. So you’re asking about, you know, as far as I’m concerned for the kind of therapy that I do, which is, you know, psychodynamic or psychoanalytic therapy aimed at self understanding, Aimed at psychological change, right? Not just aimed at managing symptoms or supporting, you know, not trying to change something, just, you know, supporting someone through a chronic condition, right? I can do that, but that’s not what I choose to do in my private practice. I’m in it to help the person to change something about themselves. It requires consistency of meetings, right? It requires enough frequency of meetings that you can actually do the work. And you know, the truth of the matter is, it’s really hard to do therapy once a week. It takes more skill to do that than to do therapy twice a week or three times a week, right? (Time 0:16:17)
Acknowledging Inner Conflicts in Psychotherapy In psychotherapy, individuals are composed of multiple conflicting parts of themselves. Some parts are allowed to express themselves, while others are suppressed. However, ignoring certain parts does not make them disappear; they continue to influence thoughts and behaviors from behind the scenes. Transcript: Speaker 1 About jumping in that doesn’t sit right with you, that feels wrong to you. Don’t we understand that? Tell me about that. So what I want to do is what we try to do in psychotherapy, the patient is not just patients, humans, all of us. We are all of many minds about, you know, everything important. And what we try and but some of those, you know, some of those parts of self get all the airtime, you know, they get to speak and and some of those parts of self get silenced or, you know, disregarded Or disavowed. But out of sight isn’t out of mind. And if we don’t hear from those parts in words, they start running the show from behind, you know, from behind the scenes. (Time 0:23:16)
Understanding the Multiple Facets of a Person In psychotherapy, it is essential to acknowledge that individuals have different parts of themselves that may not always align. Some parts of a person may dominate while others remain unheard. It is crucial to create a space where all facets of a person, especially the ones not usually expressed verbally, can be heard. Actions can also speak louder than words, indicating the presence of different parts of the individual. The goal is to articulate the unspoken aspects of a person’s psyche to achieve a deeper understanding. Transcript: Speaker 1 About jumping in that doesn’t sit right with you, that feels wrong to you. Don’t we understand that? Tell me about that. So what I want to do is what we try to do in psychotherapy, the patient is not just patients, humans, all of us. We are all of many minds about, you know, everything important. And what we try and but some of those, you know, some of those parts of self get all the airtime, you know, they get to speak and and some of those parts of self get silenced or, you know, disregarded Or disavowed. But out of sight isn’t out of mind. And if we don’t hear from those parts in words, they start running the show from behind, you know, from behind the scenes. So part of what we want to do in therapy is make is create a space where it becomes possible to hear from all of the different facets of the person, including and especially the parts we Don’t usually get to hear from in words. So you know, think about a patient who agrees to come weekly and then starts missing sessions. You know, what does it mean? Well we hear from one part of the of the person in words. I want to come weekly. I want to do this work. We’re hearing from another part of them, another part of this communicating loud and clear, except it’s not in thoughts and words. It’s in actions. The action of missing sessions. What we want to do is work to put words to what’s being communicated, you know, not in words. (Time 0:23:16)
Unpacking Patient Shifts in Therapy The patient’s recent shift in therapy highlights two key points: first, the feeling of rejection and a lack of desire to engage with the therapist, and second, the patient’s sense of shame tied to what was shared in the last session. The therapist acknowledges the patient’s vulnerability and refrains from rushing into interpretations, allowing space for the patient to come to terms with their thoughts and emotions. Transcript: Speaker 1 Same more about that. I know it’s hard to roll play, but I want to see this is really important. The patient has just made a shift from, you know, it’s nothing. It just, you know, I lost track of the time to this has something to do with two things in the last session. One is the patient sense. I don’t really want to. I don’t want to do this with him. I’m glad to be rid of him. There’s the patient’s feeling, you know, sort of rejected or that I don’t want to be here with him. And that’s really important. The second thing the patient is saying is I think it’s going to go to their sense of shame about what they shared last session, which we’re making up as we go. Their sense of shame, right? And that that’s tied to the feeling of rejection. They told me something that they feel ashamed of and the concern, the underlying concern in the background is, you know, I’m, I’m, I think I love them for it. I’m judging them for it. I’m criticizing them for it. But I don’t want to rush in with the interpretation yet because it’s too soon, right? The patient has just put the idea on the table for the first time. It’s kind of a new, they’ve just put words to it themselves for the first time. (Time 0:29:18)