First impressions in counseling prove critical

Successful addiction treatment starts in the first session. The minute the patient walks through the door, the process of building a positive therapeutic relationship begins. The stage is set for working respectfully and ethically. The first session presents an opportunity for the counselor to demonstrate the desire to be genuine and intentional in interactions with a patient. Intentionality is demonstrated when these interactions are flexible and client-centered, rather than rigidly based on any one model of care. A counselor’s intentionality is critical, especially in the first session.

Dating back to the 1990s, researchers have studied the patient and therapist factors that most influence the change process. While we frequently hear counselors cite patient motivation as the key factor dictating therapeutic change, the research finds that client factors account for only about 40% of the change process. Thirty percent is influenced by the therapeutic relationship and another 15% is influenced by the expectations that the counselor and patient bring to the start of therapy. Surprisingly, only 15% can be directly attributed to the counselor’s model of therapy and the interventions utilized.1 Given these statistics, it is imperative that addiction counselors recognize the importance of the first session and the role they play in setting the stage for positive outcomes.

The complexity that patients bring when starting treatment and the care required to meet their individual needs influence the process that counselors undertake as they develop a therapeutic relationship. Whether the treatment takes place in a residential or outpatient setting, patients present with biological, psychological, social and spiritual issues that are unique to their subjective experience of addiction and the problems that precipitated their seeking treatment.

There’s a context at this moment in time that’s unique and important. While counselors have worked with similar clinical issues in the past, they have never worked with this client, and what’s motivating that person either to seek change or fight to stay the same.

There is no such thing as an unmotivated client. From the very first meeting, the therapist begins to assess what the patient is motivated to achieve and works to meet that person where he/she is. As most counselors attest, many patients are highly motivated to stay the same. A counselor’s negative response, verbal or non-verbal, to a patient’s motivation in the first session sabotages the outcome of therapy before therapy even begins.

Client history of trauma is another significant factor in the joining process. Fifty to 90% of patients who enter addiction treatment have experienced serious trauma, and 30 to 50% meet criteria for post-traumatic stress disorder (PTSD). The initial outpatient sessions or residential days might be experienced as threatening and might trigger past traumatic memories and elicit traumatic defenses. Hypervigilance emerges as traumatized patients attempt to ensure safety and to maintain some sense of control. From the moment the counselor and patient make eye contact and introduce themselves, the patient’s need to experience the counselor as safe begins the process of the patient assessing the counselor as much as the counselor assesses the patient.

Session's clinical objectives

The primary objective of the first session is to lay the groundwork for a positive and safe therapeutic relationship. Several factors critical to success come into play. The first is the counselor’s ability to be genuine. Being genuine necessitates counselor self-awareness and a desire for emotional and relational coherence.

In the first session, counselors either succeed or fail to present as genuine through the congruence of their verbal and nonverbal communication. Patients are more influenced by counselors’ nonverbal communication, most notably body language, eye contact, and the volume and tone of voice, than by what counselors actually say. Inconsistent messages interfere with their ability to convey who they are and what patients can expect when working with them. One example of an inconsistency might occur when a counselor expresses a full commitment to developing a connected and collaborative relationship, but does so while checking the phone or fidgeting in a chair.

Counselor incoherence can be spotted a mile away. Addicts have lived a consistent life of inconsistency, saying one thing and doing another, which makes them keenly aware of this same process in others.

The second critical success factor in building the therapeutic relationship is a counselor’s ability to remain present throughout the initial session and beyond. Counselors are perceived as present when they are fully focused on the patient, while maintaining a dialogue focused on recovery and healing. Within this process, the counselor must remain grounded in the here and now, confident, non-anxious, and focused on the patient's unique story. Distracted counselors who look at their watch or can’t remember clearly stated details of the story are viewed by the patient as uninterested and unsafe.

The issue of presence is especially pertinent for counselors in the residential setting. Here, the first meeting is too often a brief encounter where the counselor is saying hello while running off to facilitate a group or other treatment activity. Again, the inconsistency of a counselor’s verbal and nonverbal communication comes into play when apologetically promising to meet with the patient later in the day, while leaving to complete other “more important” tasks. This “fly by” encounter creates the unintended first impression of a counselor who is unavailable or too busy to focus on the new patient's needs. Whenever possible, the residential counselor should schedule meeting a new patient when there’s time to be genuine and present.

Establishing an emotional connection with the patient is another goal of the first session. To do this entails counselors dialoguing with patients regarding the consequences that they are aware of and inviting them to experience and discuss any emerging emotions. This early and open discussion of fear, pain, anger, sadness and shame opens the door to talking about the difficult issues that many patients face on the road to recovery. It also opens the door for a conversation about the importance of social support and the counselor’s desire to develop a healthy therapeutic relationship. Asking patients about their thoughts on what they need for building this relationship can bring to the surface potential issues that could interfere with joining.

Many counselors describe to their patients how the relationship is an evolving process that will have highs and lows over the course of treatment. They often predict clinical issues that will trigger difficult conversations and challenge their relationship. It is often useful to give examples of these triggering issues and to normalize a patient's tendency to withdraw and seek support from peers who are also struggling to trust and make the shift from the culture of addiction to recovery.

There are many opportunities in a first session for counselors to model how they will facilitate future sessions. This modeling is best carried out while collecting information about the events that brought the patient to treatment, insight into his/her addiction, current motivation for recovery, and past treatment history.

The questions used in this data collection can take many forms. Exception questions ask patients to consider times when the behaviors, emotions and consequences that they have been describing have been absent or did not occur. Scaling questions challenge patients to reconsider black-and-white thinking and to describe issues according to where they fall on a 10-point continuum from never to always. Asking patients to address inconsistencies in how they described their problems lets them know that the counselor is listening and motivated to gain an accurate understanding of their presenting problems.

Asking patients to more fully describe what they mean when they use general terms such as “love,” “trust” and “respect” lets them know that the counselor does not want to make assumptions about their experiences. The underlying goals of these questions are to promote the counselors’ curiosity in learning about patients, to establish patients as their own experts in their subjective addiction experiences, and to begin challenging patients to assess and then reassess their beliefs about themselves and their addiction.

Review important documents

Finally, and most important, is the fact that the first session offers an opportunity to inform the patient that confidentiality and ethical practice are of critical importance to the counselor. It is for this reason that the counselor and patient should review the consent for treatment, disclosure statements, and release of confidential information that was signed at the time of admission.

The counselor must remember that patients often sign important documents with limited awareness of what they’re signing. At admission, patients are often intoxicated, anxious, dissociated or otherwise impaired while the meaning and implications for each document are explained. If a counselor makes a point to explain the scope and content of each document signed, explain what it means to consent fully for treatment, and discuss each aspect of the release of information, they are ensuring that the mandates of the federal 42 CFR Part 2 statute are followed, while also setting a respectful and ethical tone for the honest discussion of issues to come.

Seasoned addiction professionals can attest how the failure to discuss in the first session the limitations associated with the release of confidential information, especially what information and under what circumstances it will be shared with the family, almost certainly will become a point that will challenge the therapeutic relationship. Therefore, it is imperative to ask patients what information they want shared with family members, referral resources, employers or other designated individuals, and under what circumstances. Counselors need to express their view of why it might be important to share and discuss information with family members or referral resources, and to inquire if the patient is willing to collaborate on a plan for shared information.

In summary, it is critical for addiction counselors to recognize the important relationship between facilitation of an effective first session and establishment of a collaborative therapeutic relationship, in maximizing patient success in addiction treatment. Counselors will make every attempt to be genuine, present and non-judgmental as they invite patients to do the same. They will plan for collecting data, while joining and modeling the process for future sessions. And they will demonstrate a desire to work honestly and responsibly by openly discussing difficult subjects and ensuring that the patient understands the ethical implications of consent and release of confidential information.

When planning the first session in addiction treatment, successful counselors recognize that who they are is more important than the models they use, and that they will never get a second chance to make a good first impression.

Michael F. Barnes, PhD, MAC, LPC, is in private practice in Lakewood, Colo., providing clinical services to individuals, couples and families struggling with trauma, addiction and relationship issues. Barnes is also Senior Clinical Educator at CeDAR (The Center for Dependency, Addiction and Rehabilitation) at the University of Colorado Hospital in Aurora, Colo.

References

1. Lambert MJ. Implications of outcome research for psychotherapy integration. In Norcross JC & Goldstein MR (eds.). Handbook for Psychotherapy Integration. New York City: Basic Books; 1992.