This article addresses several practical issues related to beginning psychotherapy: telephone contact, the initial session, referral to another therapist, discussion of arrangements, charging for missed sessions, guidelines for the patient and interactions outside the therapy hours. It takes a question-and-answer form, dealing with with questions a neophyte psychotherapist might ask. Although the article specifically relates to treatment that is dynamically oriented, it is also relevant to other forms of psychotherapy.
How Should the Therapist Handle the Initial Phone Call?
The first contact with a patient is invariably by phone. This contact can vary from simply setting up an initial appointment to a prolonged discussion. The therapist can easily answer questions regarding fees, office location, time availability, and experience and credentials. Questions regarding the therapist's comfort and expertise with
certain types of problems, in addition to the type of therapy typically utilized, are also reasonable.
It is usually advantageous for the therapist to be friendly and open, answering relevant questions in a straightforward manner. It is not advantageous at this early time to delve into the reasons for the questions, speculate on the dynamics or make any kind of interpretive comments. At this stage, these types of interventions appear intrusive and are usually not appreciated.
If the questions become more personal, or go on and on, limits need to be set-but in a very tactful way. Phone calls resembling initial sessions are best avoided. Contrary to the expectations of some, lengthy phone conversations are not positively correlated with a potential patient's ultimate decision of whether to undergo treatment with a specific therapist.
If the therapist only has five or 10 minutes when returning the call, it is reasonable to state such at the beginning of the conversation. Sometimes it is appropriate to call the patient back if additional information is desired. For example:
Therapist: Before we start, I do want to mention that I have an appointment in 10 minutes. If we don't finish by then, I'll be happy to call you back. (then, after seven minutes) We are going to have to stop in a minute or two. If you like, we could set up an appointment. Or I'd be happy to call you back if you need more information.
What Kinds of Patients Tend to Stay on the Phone?
Long initial phone questioning is most characteristic of borderline patients. Some of these individuals are preoccupied with searches for the "ideal" therapist. Feeling quite vulnerable to the vicissitudes of relationships, they want to feel as comfortable as possible before the initial session. These patients sometimes look for therapists with whom they feel the right "vibrations, wavelengths or sensations," the ones whom they sense are similar to themselves and the ones who share similar values, philosophy and upbringing. Initial phone conversations can be reflective of these searches. With these individuals, tact and patience is of the greatest importance. Limits have to be set with the patient, but with the utmost skill and sensitivity.
The following comment was made after a 20-minute conversation in which the patient had basically found out all the necessary information and more.
Therapist: I don't want to be impolite, but I do have to go in several minutes. I do think we've covered the relevant questions about psychotherapy. Certainly I will be happy to answer additional questions when we meet. Would you like to set up an appointment?
How Is the Initial Session Structured?
Upon meeting the patient, I introduce myself, invite the patient in, and then say, "Why don't you have a seat." I then pause, allowing the patient to take the lead. If asked for clarification about what to say, I state, "Why don't you tell me about yourself, especially in reference to coming to see me today." I want the story to be presented in the patient's own way; thus, I do not interrupt, except to ask for relevant clarifications.
I am not concerned about obtaining all the details in the first session; rather, I am interested in hearing how patients talk and think, and in learning about their personalities, conflicts, strengths and weaknesses. I want them to feel as comfortable as possible, so that they'll continue the process. With that in mind, I make empathic comments if relevant, and try to maintain a friendly and interested stance.
If a patient's anxiety demands that I ask questions, I do so. Otherwise, I don't interrupt. I am particularly interested in the motivation for therapy. With that in mind, I often ask what ideas the patient has about treatment, what gain is hoped for from therapy, and how the patient thinks the process works.
With about 15 minutes left in the session, I note that there are about 15 minutes left, and that I want to shift focus. I state that although what the patient is saying is very important, I want to make sure that there is time to ask me questions. I find it rather important to make this intervention, because many patients have definite questions they "need" to ask. However, they typically do not ask unless invited to do so, at least not until the end of the hour. Then, either the session has to be extended or the patient leaves frustrated.