The First Session

The initial contacts between patients and their therapists, clients and their counselors, are among the most compelling moments in a treatment experience. The way in which a therapist or counselor handles the first telephone call and the first session is overflowing with both conscious and unconscious messages and meanings, and it sets the tone for the work that's to follow-if any. Indeed, the manner in which these opening moments are handled will not only determine whether a patient or client agrees to enter treatment, but also will speak for how the therapist or counselor will go about helping the patient or client find relief from his or her emotional difficulties.

There are many therapists and counselors who handle the initial consultation in a manner that is different from their way of conducting ongoing sessions. Some therapists and counselors will not charge a fee for this session, others will offer elaborate formulations of the patient's or client's emotional problems, and still others adopt a personal, self-revealing (and seductive) approach to the initial hour. There are many variations on this theme and none of them find support through deep unconscious validation and therefore, they are not part of strong adaptive thinking. Indeed, the emotion-processing mind and its deep unconscious system operate in the same fashion with the same deep unconscious needs and perceptions regardless of which session is at hand. Thus, the principles of technique that apply to ongoing sessions also apply to the initial hour-be it in a clinic or private office. Even so, as we shall see, there are several ways in which this session calls for exceptions to the usual rules of intervening. These will become clear as we proceed.

Some Basic Precepts

The basic principles that guide the handling of the initial contacts between patients and therapists, clients and counselors, can be stated quite succinctly, even though their elaboration and application takes some effort. In essence, these are the basic guidelines for all manner of settings:

1. With only a handful of well defined exceptions (see below), it's essential to adhere to basic principles of technique throughout these initial contacts.
   
2. Therapists and counselors should establish and adhere to the ideal, secured frame to the greatest extent feasible.
   
3. They should be mindful of their interventions from the very first moment of contact with a patient or client, whether by telephone or in person.
   
4. It's advisable as well to adopt a listening process that takes into account the manifest as well as possible encoded meanings of the patient's or client's material--interventional triggers begin with the referral source and unfold from there.
   
   

The elaboration of these handful of rules is intricate but essential. While the called-for principles of technique are identical for all settings, the issues that tend to arise in clinics as compared to private settings for therapy and counseling generally are quite different. For this reason, I'll proceed by first establishing the precepts that apply to all therapy situations and then discuss the issues that seem to be distinctive for public versus private treatment settings.

The Initial Contact

The initial contact between patient and therapist, client and counselor, is usually initiated by a telephone call made by the person seeking treatment. The following points are of note:

1. This initial contact and arrangements for the first or consultation session should take place between the healer and the patient or client. Third parties should not be involved. Thus, answering machines are to be preferred over answering services, and opportunities should be afforded to clinic therapists to make their own appointments.

2. If a potential patient or client appears unannounced at a therapist's or counselor's office, it's best to not make an appointment and to instruct the individual to call your office telephone number. To do otherwise is to support the patient's or client's frame violating behaviors-intrusion into a therapist's or counselor's office could involve contact with another patient or client. In addition, it violates the implicit ground rule that contact between patients and therapists takes place by appointment only.

3. The first telephone call should be as brief as possible. Discussions of the potential patient's or client's emotional problems are to be avoided. There are, however, several vital principles and necessities that pertain to all such calls:

• Be as professional as possible.
  
• Determine who made the referral.
  
• Referrals from professionals of all kinds-e.g., other therapists or counselors, physicians, religious leaders, etc.-are usually uncontaminated and acceptable.
  
• Referrals from a therapist's or counselor's relatives and from other patients are contaminated and should not be accepted. The same rule of exclusion applies to any potential patient or client with whom there has been or may be outside contact, such as co-workers and individuals with close ties to someone with whom the therapist or counselor also is involved.
  
• In declining to see a potential patient or client, it's best to simply state that you are not able to see them in therapy without explaining the underlying reason. In addition, it's wise to not make a referral to a colleague as this risks your contaminating that therapy as well.
  
• Be clear about the presence or absence of a suicide threat. This usually can be ascertained indirectly from the tone of the caller's request for treatment. If there's any uncertainty in this regard, direct questioning is called for. If there's the least sign of a suicide threat, the therapist or counselor should get firm assurances from the patient or client that he or she will not act on these impulses until they are seen in consultation. In addition, the consultation session should be scheduled within twenty-four hours of the call.
  
• It's also necessary to be certain that you have a time slot available that the potential patient or client can use on a regular basis. Further, short of an emergency, it's best to schedule the first session at a time that both parties will be able to commit to should the therapy go forward-i.e., ideally the day and time of the consultation should be used for all future sessions.
  
• The therapist or counselor should get a telephone number from the caller in case there's an emergency need to cancel the appointed session. The caller also must, of course, be given the therapist's or counselor's office address and told how to enter the office waiting room and instructed to wait there until the therapist or counselor comes to escort him or her into the consultation room.
  
• It's generally advisable to inform the caller that the time for the consultation session is being set aside for them and that they must assume financial responsibility for that time.
  
• It's best to not present or discuss your fee during this call. If asked about the fee, your usual fee should be indicated without further elaboration.
  
• Questions about your personal life, like your religion, should go unanswered. Those about your professional training are best handled with a general assurance that you have proper credentials rather than with a detailed description of your training and experience.
  
• Every comment and intervention made by a therapist or counselor in the course of this initial telephone call must be recognized as a interventional trigger that the patient or client may process consciously, but will most certainly process deep unconsciously as needed. This principle applies to the nature of the referral source and to any outside information that the potential patient or client has been told about the therapist or counselor. These are the kinds of triggers that are active for the patient or client in a consultation session.
  
  

The tone of the therapist's or counselor's approach to this first telephone call should be professional, concerned, but not solicitous, interested but not over-involved, and as frame securing as possible. It's well to keep in mind that the therapy begins with the first mention of your name or the first moment the patient or client found your name wherever it was published. There's no justification for departures from the ideals of therapeutic technique, nor is there good reason for instituting unneeded frame modifications. The potential patient or client is monitoring and processing these frame-related and other aspects of the therapist's or counselor's interventions deep unconsciously-an at times, consciously as well. A sound start to treatment lays the foundation for a sound treatment experience.

The First Session

The therapist's or counselor's goals

The therapist or counselor has several goals in mind as he or she approaches the first session. They include the following:

1. To determine the patient's or client's need for therapy.
   
2. To determine if there's a need for hospitalization or psychotropic medication.
   
3. To get a sense of the nature of the patient's or client's emotional problems.
   
4. To also get a sense of the patient's or client's conscious attitudes towards treatment and the type and extent of his or her gross behavioral resistances.
   
5. To indicate the belief that he or she can be of help to the patient or client, and to offer therapy as well.
   
6. To assess the patient's or client's communicative style-i.e., the extent to which he or she tends to produce narrative material and to represent active triggers and thus to identify possible communicative resistances.
   
7. To attend to the two stories that the patient or client will tell.
   - The first is the conscious and manifest narrative, which usually recounts the history of his or her emotional difficulties, and reveals their present status.
   - The second story is a deep unconscious, encoded narrative of his or her responses to the active, interventional triggering events that have been created during the referral, first telephone call, any subsequent contact between the patient or client and the healer, and the unfolding session.
   
8. To establish the ground rules of treatment and implicitly and explicitly indicate how the therapy will be conducted. In this session alone, the therapist or counselor does not wait for encoded directives from the patient or client in respect to establishing the frame. It's absolutely necessary to define all of the ground rules of treatment in the first hour. The failure to do so is unconsciously perceived by patients and clients creating a highly deviant, structureless and boundariless treatment situation. Many patients or clients will decide to not enter therapy with a therapist or counselor who fails to offer the best possible conditions for treatment-although it's equally true that for maladaptive reasons, many patients or clients will enter treatment situations that are frame-deviant from the outset.
   
9. To engage in listening to, formulating, and trigger decoding the patient's or client's material, and to manage the ground rules and interpret the patient's or client's encoded themes as needed.
10. - If a patient or client represents a triggering intervention either manifestly or in clear encoded form, and also provides a strong pool of themes, the therapist or counselor should be prepared to intervene.
    - As a rule, the encoded material will deal with frame-related triggers that stem from the referral, first telephone call, and interventions-or their lack-during the consultation session itself. The encoded material also will touch on the ground rules that are offered-and those deep unconscious sought ideal rules are not proposed.
    - In principle, it's well to be prepared to intervene interpretively and with frame management interventions when needed.
    
11. To establish a cooperative, professional relationship with the patient or client essentially geared toward the resolution of his or her emotional maladaptations.
    
12. In a natural manner, to show the patient or client the therapist's or counselor's therapeutic skills and to gain his or her trust and confidence as a healer.
    
    

There is, then, much to be accomplished in a first session. Achieving these goals is facilitated by adhering to the unconsciously validated principles of technique that have been developed throughout this book. In so doing, there are number of precepts that apply specifically to the first session. I shall take private psychotherapy and counseling as my initial and basic model, and propose the following deep unconsciously validated principles:

1. In entering the waiting room to first greet patients and clients, a therapist or counselors should do so by using their name and introducing him or herself by name as well.
   
2. An initial handshake-arguably the only moment of physical contact between the therapist and patient, or counselor and client-is optional.
   
3. The therapist or counselor allows the patient or client to be the first person to enter the consultation room. If necessary, the healer indicates which chair the patient or client should sit in.
   
4. Once settled in, the therapist or counselor should speak first. The ideal query is: 'With what can I be of help?' This opening query establishes the nature of the relationship as therapeutic, the respective roles of the participants, and the initial framework of their work together.
   
5. With that said, the therapist or counselor should sit back and listen to the material from the patient or client. This is done on two levels:
   - Manifest-The surface material conveys the story of the patient's or client's emotional problems, his or her attitudes towards treatment, readiness to agree to therapy, gross behavioral resistances, and the like.
   - Encoded-The encoded themes tell the story of the patient's or client's deep unconscious, adaptive reactions to the early interventional triggers created by the therapist or counselor.
   
6. The therapist listens silently until one of three contingencies arises:
   - The patient or client falls silent. If this happens, the best intervention usually is the invocation of the fundamental rule-explaining to the patient or client that he or she should say whatever is coming to mind.
   - The patient fulfills the recipe for intervening. The material in the first session may well include a manifest or encoded allusion to a trigger and several strong encoded themes. The therapist or counselor should then offer a trigger decoded interpretation or playback of encoded themes depending on how the trigger has been represented (see chapters 13 and 14). This type of communicating is likely to arise when ther's an active frame issue on hand.
   
   For example, a male patient who proposes the use of insurance is, in making the proposal, manifestly representing the anticipated trigger of his therapist's compliance. He then tells a story about the harm that was done when he confided in his boss, only to learn later that he had leaked the patient's secret to half the people in the office and had badly damaged the patient's reputation. He should not have done that-he'll never trust him with a secret again.
   
   The trigger decoded interpretation here runs like this: 'You have asked me to complete insurance forms to help you pay for your therapy. As the story about your boss indicates, you're well aware that this would mean that I'd be revealing your secrets to third parties like people in your office. And as you also mention in your story, that would be damaging to you and cause you harm. And if I did it, you'd never trust me again with your secrets. But you're also warning that I shouldn't do it in the first place.'
   
   Because this decision belongs to the patient, it's left to him to decide whether to heed the admonishments and advice of his own deep unconscious system. As we saw in Chapter nine, in the vignette about Ms. Benson's therapy with Dr. Wall, this kind of frame issue may take a fair amount of time to process and secure.
   
   - The midpoint of the session arrives. At this juncture, it's advisable for the therapist or counselor to indicate his or her belief that he or she can be of help, to obtain the patient's or client's commitment to enter therapy, and to structure the ground rules of the treatment (see chapter 9).
7. The specifically stated ground rules pertain to:
   A. The recommended frequency, time, and length of the sessions.
   B. The fee. The therapist or counselor should state his or her usual fee and ideally, there should be no negotiating, or discussion of, the fee. The patient or client also is told that they will not be receiving a bill, that they should keep track of the number of sessions held each month, and pay for the previous month's session at the beginning of the first session of the new month.
   
   There's no need for a bill because the patient or client can easily keep track of the number of sessions held each month and the bill is sometimes used by patients or clients as a transitional object.
   
   If it's clear that the patient or client intends to continue in therapy, the fee for the consultation session, which should be the same as the fee for all other sessions, can be paid in the same manner. If there's any question about going forward with therapy, the therapist or counselor is well advised to ask to be paid for the consultation session when it's nearing its end. In addition, payment by check or money order is preferable to cash payments. The patient's or client's financial responsibility for all scheduled sessions also needs to be stated.
   C. The need for total privacy and confidentiality on both parts.
   D. The fundamental rule of free association, namely, that the patient or client should, in each session, say whatever comes to mind as he or she has been doing during the first session.
   E. The therapist's or counselor's vacation policy-that he or she will take off some three to four weeks each year and that these vacations will be announced well in advance-and the advice that sessions will not be held on major legal holidays.
   F. Implied ground rules, such as the therapist's or counselor's relative anonymity and the absence of physical contact between the two parties to the therapy, do not need to be stated because the responsibility to enforce them generally lies with the therapist or counselor - they are usually demonstrated rather than verbally stated ground rules.
8. In keeping with the principle of crafting the first session as closely as possible to the design of all future sessions, the length of this session should be identical to that of all other sessions-there's no need to make it longer or shorter than the rest.
9. With patient or clients who do not commit to further therapy, it is inadvisable to keep time open for them until they let the therapist or counselor know their final decision. If they do call and decide to go forward, the time of future sessions should be established during that telephone call.
10. If need be, the only information that the therapist or counselor should record is the name, address, and telephone number of the patient or client.
    

It bears repeating that the principles that guide a therapist or counselor through the initial telephone call and first session are, in substance, the same as those that apply to ongoing sessions. There's a good deal of temptation to be lax about adhering to the ideal frame, to be unusually active, to seek facts rather than allow the patient or client to free associate, to actively conduct a mental status instead of doing it by observing the patient or client as he or she speaks, and a host of other impulses directed towards departures from the unconsciously sought ideal frame. They should be avoided at all costs. The patient's or client's deep unconscious system does not go to sleep during these initial contacts, but is busily monitoring and is deeply affected by the therapist's or counselor's approach to treatment and especially to its frame. Departures from the ideal ground rules are duly noted and they have a strong deep unconscious influence on the patient's or client's decision as to whether to proceed with therapy.

Frame modifications in structuring a treatment create the conditions under which many patients and clients will accept therapy for unconscious, maladaptive reasons. They create deep unconscious expectations that additional frame modifications will be forthcoming and frame violations become the preferred mode of attaining maladaptive relief from existential and other forms of death anxiety. Requests by these patients and client for further frame modifications abound. And even though the patient's or client's deep unconscious system will emit encoded messages that speak for holding the frame secured, the patient or client consciously often will be adamant about having his or her pathological, frame-violating needs satisfied. And while these frame modifications will be accessible to repeated working through-patients and clients will encode their deep unconscious experience of these errant interventions from time to time throughout their therapies-these early frame modifications are very difficult to rectify and they cause no end of trouble for all concerned. Predatory and predator death anxieties in both the patient or client and their healer play a notable role in these disruptive effects-each arty to therapy is predating the other (see chapter 8).

On the other hand, the offer of an ideal, frame-secured treatment experience will always evoke and be a test of a patient's or client's secured frame death anxieties. There will be the typical two-sided, deep unconscious response to ideal conditions for therapy-a strong sense of holding and security on the one hand, and the activation of existential and predator death anxiety on the other (see chapters 8 and 9).

In first sessions in which the frame is quite secure at the outset and is explicitly secured by the therapist's or counselor's explication of an ideal set of ground rules, the patient's or client's deep unconscious system is very likely to generate a series of encoded themes in this first session-a secured setting is a powerfully evocative trigger. Lest the patient's or client's entrapment, existential anxieties become too intense and he or she flee treatment, the themes will need to be subjected to a trigger decoded interpretation. Encoded validation is likely to follow, but the intervention cannot be expected to resolve in a single stroke these powerful deep unconscious anxieties and the emotional issues with which they are linked. Indeed, such work will occupy much of the future therapy. The main goal in the first hour is to offer the patient or client sufficient insight into these anxieties to enable him or her to continue with treatment under secured frame conditions.

The Initial Contact in Clinic Settings

I shall use clinic settings as the model for all non-private settings in which therapy or counseling is conducted-outpatient clinics, half-way houses, in-patient settings, government run facilities, and the like. The following are some of the main problems that arise in these compromised but highly necessary settings, and some of the principles that can serve as guidelines to making the therapies conducted under these conditions as healing and non-damaging as possible:

1. The simplest and most basic precept is this: Every effort should be made to create conditions and offer ground rules that come as close as possible to the ideal frame and approximates as closely as possible the ideal conditions available in a private practice therapy situation.
   
2. There are many frame violations-as measured by deep unconscious system standards (see chapter 9)-that are common to clinic settings and yet are frivolous and unnecessary. Every effort should be made to avoid or rectify these frame violations.
   
3. Examples of this kind of generally unnecessary frame modification include:
   A. Having secretaries and other third parties make appointments for the therapists and counselors.
   B. Giving third parties responsibility for collecting the fee.
   C. Requiring more than the minimum amount of record keeping.
   D. Keeping records where many people have access to them.
   E. The use of public waiting rooms instead of having small waiting areas outside of a given therapist's or counselor's office.
   F. The lack of adequate soundproofing for the therapy offices.
   G. Unnecessary casual discussions of patients or clients with colleagues and other clinic personnel-all too often in earshot of the patient or client, or others.
   H. The leakage to patients or clients of personal information about the therapist or counselor, and about other clinic workers.
   I. The improper, unauthorized release of information about patients or clients to third parties-a practice that should be kept to a minimum and require a written, informed release from the patient or client.
   J. Arranging for a therapist or counselor to see two members of the same family or two people who know each other socially.
   The list of unneeded frame violations in clinics is seemingly endless-grim testimony to the conscious neglect of the ground rules and the power of secured frame anxieties in human beings.
   Every therapist or counselor who works in this type of setting is well advised to review clinic policies and the behavior of clinic personnel for frame violations and to do as much as possible to correct these harmful departures from the ideal, healing frame.
   
4. A word of caution about such efforts at rectification. In general, human secured frame, existential and predator death anxieties are far stronger and more threatening than human predatory death anxieties. This means that most of the individuals working in a clinic-professionals and non-professionals-suffer from significant amounts of secured frame anxieties and have a strong conscious preference for deviant frames. This is nature's default position.
   - As a result, the reformer is almost certain to meet conscious opposition and to evoke angry responses from clinic personnel that are unconsciously driven and irrational. He or she should proceed with great caution in trying to bring about changes in clinic policy. These changes are a dire necessity, but they go against the grain of conscious system defenses. The effort to put reforms in place creates very delicate situations that need to be handled with the utmost tact. If possible, efforts at education-including the teaching of the main principles of the strong adaptive approach-are called for.
   
5. As for doing therapy or counseling in clinics, the basic principle is that, given the focus of the patient's or client's deep unconscious system, much of the therapeutic work, if it's strongly adaptive, will, of necessity, revolve around the frame deviations built onto the treatment situation and experience.
   A. This work should, of course, be guided by the patient's or client's representations of triggers and his or her pool of encoded themes.
   B. Clinic therapies are deviant frame therapies, and the trigger decoded interpretations and deep insights that a therapist or counselor can offer will be based on the patient's or client's deep unconscious experience of the particular conditions of treatment.
   C. From time to time during a clinic therapy, then, one or another deviant ground rule will come to the fore-something related to the ground rule will take place-and the therapeutic work will center on the patient's or client's deep unconscious perceptions of the trigger and connections to past life experiences ae likely to emerge. In this way, the patient's or client's maladaptations, as linked to these triggering events, can be worked over and hopefully resolved.
   
6. Such therapeutic work should, if at all possible, be supplemented by the creation of secured frame moments, during which the patient's or client's secured frame anxieties can also be worked over and resolved to the greatest extent feasible under these conditions.
   - The opportunity for this type of therapeutic experience generally arises when a patient or client requests a fresh frame modification-e.g., a change in the time of a particular session, a reduction in the fee, a meeting between the therapist or counselor and a third party-and the therapist or counselor, using the patient's or client's encoded themes, refuses the request. Properly managed and interpreted, these interludes are quite healing for the patient or client-and quite rewarding for the therapist or counselor as well.
   
   

Clinic therapies serve to remind us that the psychotherapy and counseling experiences are not constituted by a simple unfolding of the inner life of a patient or client. They are interactional happenings in which the ground rules and interventions offered by therapists and counselors from one minute to the next activate the deep unconscious perceptions and remembrances of the patient and client as he or she tries to adapt to these interventional triggers. The therapeutic experience is a mutual creation of patient and therapist, client and counselor, but it's not created in their minds or to be seen as two minds interacting. It's created by actions and inactions, verbal and otherwise, as each creates triggering events for the other to adapt to-and hopefully learn from.

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