The First Interview
We are going to present some psychological insight for young therapists who want to do a better job during the first interview, during that first meeting with a new client where the important early clinical picture is developed and rapport is hopefully established. This is not meant to be an exhaustive presentation but rather to provide some ideas to help augment what you’ve already learned.
A lot of therapists hope to come to a diagnosis by the end of the first session. It was Irvin Yalom who said that it’s funny how the better you get to know a patient over the weeks and months the less sure you are of your initial diagnosis. It’s easy to pigeonhole people, to miss their complexity, to focus in on one or two symptoms and then jump to a blanket diagnostic conclusion when in actuality those symptoms only represent one tiny dot of the life constellation or are the manifestation of deeper drives, motivations, and worldviews that have little or nothing to do with the diagnostic label being applied.
We believe that diagnosis does have its place, especially with the severe and persistent disorders where accurate diagnosis allows for specific treatments that are absolutely necessary to change the course of some debilitating mental illnesses. But many people are diagnosed with the wrong things, and even more don’t qualify for a diagnosis at all but are simply experiencing existential problems of living that all curious and reasonably intelligent human beings face and must attempt to overcome in one way or another as they move through the lifespan.
For us the general rule is to be extremely cautious in labeling people with any kind of mental disorder since not only is it likely incomplete in the first place but also the cultural stigma attached can do tremendous damage to the psyche and sense of Self. The only time to present a diagnosis is if after careful evaluation you believe that your client finally being to conceptualize and categorize all the strange occurrences that have been causing life problems outweighs the stigma.
Anyway, your client walks through your door for the first time. You can start gathering information right away. Notice body language. Is the back straight, is eye contact direct? Or is the gaze furtive? Are body movements purposeful or hesitant? Does anything about external behavior strike you as off, even if you can’t name why? Does there appear to be good hygiene? Are the finger nails trimmed or long, clean or dirty? Are clothes wrinkled or well-pressed? Are there any scars, bruises, or marks on the arms, legs, or face? Any tattoos? Any jewelry? Bloodshot eyes, dilated pupils? The list goes on and on of course. The key is to be observant, not judgmental.
Of course we need to remember that there’s not exactly a ‘normal’ for dress or hygiene or behavior. And the first time meeting with a mental health professional is anxiety inducing under the best of circumstances, terror inducing under the worst. No one likes being under the microscope. An aggressive facade could be a way to hide the fear underneath. A timid facade could be a way to hide aggressive or destructive impulses.
You just don’t know yet, because you have no access to the underlying character structure that would help you put all the incoming stimuli in its correct context. But at the same time a disorganized or careless appearance is a signal you don’t want to ignore. When most people go to important meetings in public they care about their appearance, and it’s clear they’ve taken some time to present the best possible external version of themselves. But with the severe and persistent disorders, and even with lighter forms of depression, self-care usually goes out the window.
You’ll probably invite your client to have a seat. You want to be aware that pretty much everything you say and do could have distorted a meaning for your client because of transference and because of the unavoidable power imbalance. You represent authority, you have the power to apply a diagnosis with tremendous social weight behind it. You represent a power structure that has put people away for long periods of time, a power structure that has experimented with lobotomy and shock treatment. Why should this person trust you? Have you proven your trust worthiness in any way other than obtaining a degree sanctioned by a power structure with a checkered history?
This is the real paradox, that we fully expect people to divulge intimate, embarrassing, scary and difficult aspects of their lives right away to complete strangers who have done nothing to merit their trust.
Our recomendation is to bring the above out into the open right away and to clearly lay out the specific rules of confidentiality to your client before any signatures are obtained. We’ve heard some professionals say they get their clients to sign a bunch of different paperwork right at the start while it’s all kind of a blur for them and we think this is complete garbage. Make sure they really understand the details of what they’re signing, have them repeat the most important points back to you. Specifically in terms of the confidentiality agreement, how do you as a professional interpret danger to self or others? How do you interpret child abuse? How far would things have to go before you intervened?
Danger to self or others is a scary one. No one wants to lose a patient or have that patient hurt someone else under their watch when it could have been avoided by acting faster or noticing signs that were obvious in retrospect. So you’ve got to clarify for yourself what you’re looking for.
A lot of young professionals are nervous about bringing the topic of suicidal ideation up at all, as if they’re somehow being disrespectful and uncouth for even mentioning it, or as if they’re implanting the idea of suicide into their clients’ heads. But you don’t need to worry about that. If they aren’t suicidal they’ll say that. If they are you’ll be glad you asked and you’ll have gained invaluable information about the very first place you and your client need to be paying attention. Really taking the time to assess suicidal ideation and putting a clear plan in place to prevent it is a tangible sign that you care about the welfare of your client. You can say that as you assess for suicide risk. There’s no judgment, only concerned interest. You can also say, and just as importantly realize for yourself, that if and when you break confidentiality to get them help because they are an immediate danger to self or others it’s not to punish them, it’s because you care about them and their long-term health and happiness. If they’re in a place where they’re about to make a huge mistake you’ll be there backing them up, like a safety net.
Most clients really love this. You’ve got to understand that people who seek professional help for life problems are often coming from very challenging environmental situations where they may not have had a lot of support, a lot of people who really took an active interest in their growth and happiness. They may have grown up in abusive or dysfunctional or traumatic situations. It feels really good to be able to count on someone, to have someone in a position of authority decide that you’re worth the time and effort. We all know this from our own lives. You have the chance to be that person in the lives of your clients.
Alright, so hopefully the confidentiality agreement has been signed and you’ve clearly laid out limits to confidentiality and other important policies. You’ve hopefully already squashed the elephant in the room by allowing the unfair power imbalance to be stated clearly, and you’ve given your client a chance to express any thoughts, feelings, or misgivings. During this time, although you’re attempting to subjectively connect with your client, to be in the room in a personal and present way, you’re also taking a step back to try to make some objective observations. Don’t let confirmation bias rear its ugly head here. Remain completely open to possibilities. These are very early impressions and feelings, nothing more.
Many young professionals find it difficult to know exactly how they’re supposed to act with their clients. It’s almost like they exhaust themselves trying to live up to the role of what a therapist is. Don’t sacrifice your own personality in the name of ‘professionalism’. The fact is that professionals of all different styles and constitutions do excellent work. What’s important is finding your own authentic style, being you rather than trying to play a part, because people see right through fraud and inauthenticity even if they don’t bring it up or banish the thought from conscious awareness. They’ll be turned off without knowing why. And why on earth would they be authentic and honest when the person who is supposed to be taking the lead in the encounter is being inauthentic and dishonest. You’ve got to lead by example, and this means having the courage to be you in the human encounter.
Instead of scrambling to ask every single question to get all those boxes checked, feeling hurried and stressed and putting that discomfort into the room, take on a relaxed professional demeanor and give the conversation a little more room to flow. When you leave that space open you might be floored by the pertinent information clients provide all on their own. Of course some are taciturn, they stay cautious and guarded, but many have been waiting a very long time to get material off their chest. They have a presenting problem, an idea of how things have gotten to this point. They might be right, they might be wrong, but it doesn’t matter because they’re ready to talk if you let them and it’s not their job to know if their clinical assessment of themselves is right or wrong it’s your job. If you trust the conversation to go where it will instead of trying to keep very tight control over its course you’ll have plenty of opportunities to interject questions. But these questions will sound and feel natural to your client rather than forced and uncomfortable. When people aren’t being hounded, when they don’t feel like they’re under the bright lights because someone believes they’ve done something wrong, they love being the center of attention. If you’re authentically curious and engaged they sense it and they respond to your questions with enthusiasm and wonder as your follow up questions start to take them into a deeper understanding of their psychological situations.
Many young professionals worry about the best way to start the conversation off but that worry is unnecessary. Most clients are chomping at the bit to tell their stories, to get what’s been bothering them off their chests. A simple “What brings you in today?” is enough for them to get going and you’re off to the races.
What’s important to remember while your client is describing the presenting problem is that this isn’t a time for you to do a lot of talking or to interrupt much. This is your client’s moment to shine. What you do want to do is give behavioral cues to show that you’re interested in and engaged with your client’s story. Actually if you have to fake your curiosity you’ve probably chosen the wrong line of work. If you and your client don’t leave every session energized, feeling like something really interesting just occurred, then you’re both doing something wrong.
So be fascinated but don’t try to take the lead in the conversation and don’t try to force a change in the topic. You can learn much more just by sitting back and paying careful attention to what’s being said. The biggest thing you want to do in the global sense is to look for coherence of the story. Do all the parts seem to fit properly together? Are there any contradictons? Does the timeline work? If the story doesn’t fit together well, or if it’s full of holes, or if the sequence of events is all wrong, or if anything just feels off to you then it’s further but by no means certain evidence that alcohol or drug abuse or a severe and persistent mental disorder or a combination could be in play. Many people struggling on their own with mental disorders self-medicate with drugs or alcohol in an attempt to dull symptoms. The unfortunate reality is that drugs and alcohol usually do provide some relief at first but end up exacerbating, not diminishing, the symptoms and severity of the disorder.
During your client’s presentation of the presenting problem you can of course learn much more if you’re paying attention to the underlying psychology. This is where having a very firm grip on at least one but hopefully several psychological disciplines is important. As the story unfolds you can start to make some educated guesses about what moves and motivates the living individual in front of you. You can quickly become aware of unspoken norms and values your client holds, of beliefs about Self, others, and the world, of common faulty thinking patterns, of religious orientation and moral compass, of hopes and aspirations and fears and anxieties, of hidden despair, of confidence in abilities, of whether locus of control is predominantly internal or external, of any obsessive thinking or possible compulsive behavior, of optimism or pessimism, of characterological structure dominated by masochism, sadism, or emotional detachment, of typical strategies of responding to conflict in human relationships and the world at large, of level of education and intelligence, of speech patterns typical of various socioeconomic groups or regions, the list goes on and on.
Have you ever wondered how psychics make such accurate statements about life history? It’s not magic, they’re simply cuing in to body language and countless other spoken and unspoken signals to help them make educated guesses. More often than not these educated guesses end up being right, at which point people exclaim “You couldn’t possibly have known that!” But when you have a psychological system at your disposal you don’t need every detail of the story in order to provide other details that end up being eerily spot on. Sometimes you only need one small piece of information and the whole story falls into place. Any psychologist worth their salt theoretically can do much better than psychics do, can make a guess about some aspect of the client’s life that only the client knows and end up being right. It’s just that most psychologists aren’t charlatans, they don’t use their theoretical knowledge in order to trick people into believing there’s a supernatural connection. The psychological theory is there to help find patterns out of the supposed chaos. The deeper and wider the theory, the better the chance that your conclusions will be pertinent and fruitful.
So commit yourself to becoming a high level expert in at least one renowned psychological discipline. Read all the books from all the greats in that discipline. We recommend psychoanalysis, existential psychology, and Buddhism above all other disciplines, and highly recommend all the works of Erich Fromm, Karen Horney, Otto Rank, Thich Nhat Hanh, Frederick Nietzsche, Irvin Yalom, and Viktor Frankl.
But having a solid psychological system at your disposal is only part of the battle. We’ve got to remember that while many of us rely almost exclusively on our rational sides and think of the people around us as overly emotional many of us rely almost exclusively on our emotional sides and think of the people around us as overly rational. All of us are wrong until we realize that the rational and the emotional are supposed to exist side by side, that they’re ways of processing incoming information that work best in tandem.
The psychological theoretical structure you use is the rational side of your own psychological coin. You’ve also got to be focused on the emotional side, on cultivating basic empathy, on thinking about how you are in the room, on trying to engage in an authentic human relationship. It’s no secret, or should’t be anyway, that therapists are drawn to theoretical disciplines that fit their own phenomenological experience. They, like all human beings, want to insure that their subjectively held beliefs are objectively valid.
There are a lot of counselors out there who do a great job despite the lack of a large rational theoretical structure. They rely a little bit more on their gut, on the power of the authentic human relationship to pull out thoughts and feelings from the client that lead to greater understanding of Self and world. All professionals should seek to be more present and mindful, to allow their intuition along with their rational side to guide their counseling responses and interventions. Emotions are not facts, not necessarily at least, but they do give us powerful, visceral, and immediate clues about our environments and we would do well to listen to their messages.
So whichever side you’re weaker at, whichever side you ignore by rationalizing away its right to exist, is the side you should pay focused attention to developing. Don’t neglect the side you’re stronger at of course. Continue developing that side too, because that’s where the natural skill is which means that’s probably the side you’ll be able to develop further and deeper.
But pretty much all the psychological disciplines now agree with what Carl Rogers touted, that the human relationship between therapist and client is of upmost importance, that without the sense of a good working relationship the therapeutic endeavor will fail. If therapy is successful then your client is going to see you in many different lights over the coming weeks and months. As a father or a mother, as a sibling or an old friend, as a god. The psychology of transference tells us that your client will see you in distorted ways. It makes sense that this would occur since if the encounter is human and authentic then the nature of the power imbalance will make it mirror the primary relationship or other important relationships where power was in play. And what happens is that the healthy therapeutic relationship helps clients heal by sort of getting to redo their development and thereby make amends for other unhealthy unavoidable power relationships.
This is probably a good place to talk about the nature of authority since like we already touched upon you and your client enter into an unavoidable unequal power relationship where you wear the trappings of authority. You have no idea as of yet how your client perceives authority or what the nature of his or her relationship to various authority figures has been. But what you do know is that you have certain actual and assumed advantages over your client. You hopefully have superior psychological knowledge, you have your own comfortable office space, you have your degree and education, you don’t have to say much about yourself and get to ask all the personal questions, you have the power to officially diagnose and like we said under certain circumstances like immediate danger to self or others or the abuse of a child the power to break confidentiality and even force treatment at a hospital or institution with or without say so.
The power and authority you hold in the therapeutic relationship are very real. Luckily power and authority are not necessarily bad. What it comes down to is whether authority is rational or irrational. As a therapist, you want to always be seeking to make your relationship with your client be defined by rational authority, and you want to of course have a very clear idea in your own head of what that means and be able to clearly lay it out to your client as early on as possible. It’s a good bet that the vast majority of the power relationships that have occurred over the lifespan of your client have been defined by irrational authority, by what we might call abusive authority.
Irrational authority exists to keep the power imbalance the same way forever. This type of authority is concerned with power over not power for, it’s concerned with amassing and retaining as much power for oneself as possible in order to continue to enjoy the unfair psychological, emotional, or practical benefits gleaned from that unfair power imbalance. This same psychology applies whether we’re talking about authoritarian governments or tyrannical parents or sadistic teachers and coaches. What this type of authority says is “Questioning my power, questioning the way things are, is bad and will be punished.” Irrational authority hates curiosity, hates the striving for growth, hates intelligence, hates resistance and rebellion, hates anything that threatens the foundations of the current power structure since certain desired benefits are derived from the power structure remaining as it is. Irrational authority is usually smoke and mirrors, it’s the utilization of fear, propaganda, and the various cognitive biases that make unwitting people malleable. For those who wield irrational authority it’s the trappings that count, it’s wearing the right clothes and employing the right rhetoric and clearly establishing the aversive consequences of disobedience. But this authority isn’t necessarily and usually isn’t based upon any real knowledge or ability.
Rational authority, the kind of authority you should always be seeking to create with your client from the first interview onwards, is based upon actual knowledge and skills, is always open to questioning, and seeks to eradicate the power imbalance through the passing on of knowledge and skills. As a therapist, you’re kind of like a good parent in that your work is done when your client no longer needs you and is capable of moving forward with life alone. As a new therapist, you might dread the idea of termination, that your client will want to stop seeing you and that this will mean you’re a bad therapist. In actuality, if your client stops seeing you because of new ways of thinking and being that allow for the better managing of life you should be jumping up and down in celebration not disappointed.
In the therapeutic relationship, and this goes from the first interview onwards, we need to be concerned with fostering independence not dependence. But therapists are as guilty as anyone else of sometimes glorying in states of being that aren’t healthy for them or their clients. And the main culprit in the context of this section on authority is growing intoxicated with having their clients see them in distorted godlike ways, falling victim to letting the relationship be defined by irrational authority where the therapist always know best and where emotional and psychological dependence is actually fostered not eradicated.
You’ve allowed your client space and time to air the presenting problem. This usually lasts around fifteen minutes, though a little more or a little less is fine since again what you should be interested in is allowing for authentic encounter rather than sticking to some arbitrary script. But you’ll be able to tell it’s time to get more active as they start wrapping it up and then look expectantly to you for answers. This is hopefully pretty obvious by now but in the first interview you definitely don’t want to respond to that expectation by giving a neat, tidy answer. Now is the time to expand not contract, to investigate the situation from many different angles.
The client consciously wants a quick, tidy answer from you that will solve everything of course but unconsciously what’s desired is an answer that’s already been determined to be wrong so that the anxiety around not being able to effectively manage life and relationships can be reduced through confirmation that the professional has no idea what to do with the given situation either. We have to remember that if clients were able to sort out whatever the current dysfunction in their lives is then they probably wouldn’t show up for therapy in the first place. Of course there are some people who seek therapy purely for its growth aspect, they’re doing well and want to do even better, but the majority show up because underlying conflict and the various neurotic life solutions used to deal with this conflict are now breaking down under the pressure of lived experience. They’ve got a problem, but they’re ambivalent about hearing a solution, both because this would mean they fell short where someone else is capable and because they’ll have to change entrenched patterns of thought, emotion, and behavior. Very few of us are ready to surrender our current mode of being in the world. Changing would mean the death of our current Selves and most of us fight to keep ourselves together.
Probably the best thing you can do right after hearing the presenting problem is to simply mirror back some of the most pertinent points to show you were paying attention and understood what was said. This might sound obvious but all of us interpret the same raw data a little differently. We all believe we live in the same objective world but we actually live in millions of subjective little bubbles. We project our own interpretations onto people and the world in an attempt to smooth out the conflict around the sneaking suspicion that our truth might not be the truth. So it really is of practical importance that you repeat back in your own words what your client has just said. This doesn’t just go for the first session but for subsequent sessions until you feel reasonably confident that you’ve joined together in the therapeutic endeavor, that you’re seeing things in similar ways and using the same lingo. At first you’ll often be surprised by how differently you understand certain words or ideas, by the disparate meanings you attach to the same objective event.
At any rate you should definitely work to express a positive, hopeful attitude around your client’s chances of getting better. No reproachful looks, no signs of doubt, no uncertainty, just a friendly but businesslike approach to learning more background information. You’ve got to cultivate this attitude within yourself of course, you’ve got to believe in the first place that people are capable of changing and capable of improving their situations for the better. It means you’ve got to be actively working to improve all aspects of your own life, to practice what you preach, to make sure there’s little dysfunction keeping you from walking your unique path of growth and self-actualization. If you feel full and healthy and buoyant in your own life you’ll believe others are capable of it too. If you don’t you won’t, and regardless of what you say your clients will pick up on that and their chances of improving will go down dramatically. So much of life is a self-fulfilling prophecy. If we believe we can do it we try, which puts us in position to find success. If we believe we can’t do it we don’t try or we give a half-hearted attempt, which puts us in position to fail. So you’ve got to instill that hopeful attitude into your client from the very first interaction together. Remember that you’re the unwitting fill in for mother or father, at least at first before that’s all analyzed and the distorted transference relationships makes way for the authentic human relationship defined by rational authority.
This is really the heart of human psychology actually, it’s the competing and contradictory human needs to become independent entities and to latch onto and merge with the entities around us. It’s the contradictory needs to grow and to go back to the womb. As human beings we’re born into the contradictory state where we are each of us isolated within our own encasings, each only with direct access to our own thoughts and feelings. We can guess the thoughts and feelings of the people around us, and actually we often take these guesses to be hard fact,but we can never know for sure what they’re thinking and feeling. We’re isolated from one another and therefore forever reaching across the existential divide in search of connection.
The sense of isolation all of us inherit as sentient beings aware of ourselves as separate entities is a big reason why cultivating an authentic human relationship, why really seeking to connect at the human level with your client, is so vitally important. None of us can hold up for long when that sense of isolation grows too severe. In fact, we could call the total sense of isolation, with no sense of connection to anything or anyone, insanity. Those with a religious orientation would call it hell. Whatever we choose to call it, there is nothing more painful than becoming poignantly aware of our existential isolation and the only cure for it, the only balm, is authentic human connection.
Therefore fostering authentic human connection is fostering freedom and eventual independence. Meanwhile fostering a sort of masochistic, irrational authority relationship where you are the powerful presence with all the answers and your client needs only follow your directions in order to get better is fostering slavery and dependence. Remember that you start setting the tone from the very first contact you make.
Remember that your therapeutic relationship is supposed to help set the example for, not take the place of, other relationships in life. You’ve got to set that expectation from the start that the therapeutic endeavor is not just going to be talking about ideas or increasing insight but about turning that insight into a tangible plan of attack that will be implemented in order to change the situation for the better. These are the Buddha’s four noble truths in a nutshell.
1. We are suffering and are aware that we are.
2. We recognize the origin of our ill-being.
3. We recognize that there is a way of overcoming our ill-being.
4. We accept that in order to overcome our ill-being we must follow certain norms for living and change our present practice of life.
(Erich Fromm, To Have or To Be, pg. 137)
As a psychological interviewer you’re going to be asking lots of questions. The biggest thing is to be genuinely curious. Call it respectful curiosity. In fact, before asking any questions at all we recommend that you show that respect by being transparent that you’re going to be asking a lot of personal, potentially embarrassing and anxiety inducing things. We recommend that you tell your client to feel free not to answer any questions that cause too much discomfort, which will paradoxically probably set the stage for this person deciding to divulge more intimate details not less. Giving the client the power to answer or not answer your questions is a symbol for your commitment to fostering a relationship based upon rational authority and freedom rather than irrational authority and persuasive control. Your client should have the right to keep private information private, to only share those private details when trust and dependability have been cultivated.
Like we said you’re never going to get all your boxes checked in only one hour. You hopefully already know some of the most important areas to go over in detail, like family history, medical history, mental health issues, any past work in therapy, orientation times three, danger to self or others, etc. To us what matters much more than coming to a neat clinical diagnosis is establishing rapport. If your client never comes back for a second session then what you did during the first interview was largely a waste of time, regardless of how well you think you followed technical guidelines. The therapeutic relationship is a living relationship of growth and change, one that will end up affecting both of you in ways you can’t predict or categorize. Be present, be curious, be yourself, try to notice everything, ask questions meant to expand understanding not narrow it down, be aware of and address the power imbalance, and good things are probably going to happen.