Posted by: Steve Andreas in: Articles
Note: my old email address firstname.lastname@example.org no longer works. To email me, please use my new address sandreas44 [at] gmail.com.
A variety of studies find that overall the median number of sessions that a therapist has with a client is one — roughly half of all clients don’t return for a second session. Whether or not they intend it, many therapists are doing “single-session” therapy a lot of the time. When you realize that there is a better than even chance that your first session with a client will also be your last, that can focus your attention on doing everything you can to elicit a useful change that the client wants. If you are cautious, if you allow the client to ramble on, or if you spend most of the first session taking a history or doing a genogram, you will have very little time left to do anything useful.
One thing you can do to maximize your impact is to be very specific about what you do in therapy. One of my favorite reminders is that “An ounce of framing is worth a pound of reframing.” If you allow the client to set the frames for what will happen in your sessions, and their frames aren’t useful, you will have to waste time reframing. In contrast, if you begin by offering useful frames for what you do, the client will usually accept that direction — or they will have to work to reframe it.
Everything you say — or do nonverbally — in the first session will participate in setting a direction for what will occur in your sessions. Pause now, and imagine that a new client enters your office. Allow your unconscious to surprise you with a detailed image of this specific client. Notice how this client is dressed, his or her posture and attitude, facial expression, etc. How do you greet this client for the first time? As you hear yourself greeting him or her, listen to what you say and how you say it. The messages embedded in any discussion of fees, insurance, missed sessions, or other logistics, and any “small talk” that occurs before you get down to work may be as important in setting frames as what you say when you are ready to begin. Your nonverbal behavior may also be more influential than the verbal, but it’s very difficult to discuss that in a written article.
However, let’s examine the words that you say to a client after the preliminaries and logistics are done, and you are ready to get down to work. What is a typical sentence you might say to start the session? Pause now to write this sentence down. If you think of several different possibilities, write them all down, so that you can examine them later and learn from them. (If you don’t pause to do this, you will rob yourself of a valuable learning experience.) . . .
Below are actual first sentences to clients, taken verbatim from videos or from transcripts of sessions, many of which were conducted by widely-known and well-regarded therapists. As you read each sentence, imagine being in the position of the client. Notice how each sentence directs your attention in a somewhat different way, and how you respond to it. Again, to learn the most from this article, jot down a few words or brief notes about your response to each of the sentences below, before reading the next one. (Again, if you don’t pause to do this, you will rob yourself of a valuable learning experience.) . . .
I hope it’s clear that there is a huge variety in how these sentences direct attention by setting (or not setting) frames. What does each of these sentences presuppose or imply about what will (or won’t) happen in the session? Below I have noted some aspects of each of the opening sentences listed above; perhaps you will notice others:
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What, specifically indicates that we will not be working with general outcomes, which is where most clients start, in contrast to a specific behavior that is needed in a specific context.
do you need (vs. weaker “hope,” “like,” “want,” etc.)
to be able (optional whether they do it or not, presupposing choice.)
to do (a behavior, vs. thinking, speculating, attitude, etc.)
that you cannot yet do ( “Cannot” points them to something they can not do (can=able and not=avoid), something they are able to avoid doing. “Yet” implies that it is something they will be able to do in the future. This tends to eliminate things they believe are not possible or that they never expect to be able to do.
and (links the foregoing with what follows below; “If you do what I ask, we will make it happen.”)
we (cooperatively together)
will make sure (test the results)
you can do it (strong hypnotic command, with downward tonal inflection)
before (time specified)
you leave here today (since they will, in fact, leave here today, this implies that the entire utterance is also true)
The whole sentence starts out sounding like a question, but ends as a statement. With a downward inflection at the end, the entire sentence becomes a gentle, but even stronger command. After I say the words I shut up, leaving them to ponder the answer without any help from me. Sometimes they will negotiate with themselves and sometimes they will say things that don’t answer the question. It is important to let them respond before you do. Then, your participation amounts to repeating the question, “So…what, specifically, do you need to be able to do that you cannot yet do and we will make sure you can do it before you leave here today.”
I have often had to repeat the question twice, but rarely three times. They quickly figure out that they need to answer the question before we move on, and I don’t negotiate with them.
The most common issue we encountered with this sentence was that the client would often begin by saying, “I feel—” or “I want to feel—” We would interrupt as soon as possible, and bring them back to what they need to do. One effect of this interaction is that our clients were learning to respond to their environment instead of to their own emotional responses.
Beginning the therapeutic session with this framing we were able to immediately focus on the specific behaviors and contexts where our clients needed to perform better, and we avoided having to listen to long historical recitations. When our clients identified the specific “do” that they “needed” to do, it was usually easy to arrange for them to do it. Our clients achieved better outcomes more swiftly, and we felt refreshed at the end of the day.
This does require that you have many excellent methods to accomplish these kinds of well-formed outcomes, so that you can keep your promise. If you find this prospect daunting, that indicates that you need to develop specific skills.
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From the examples above, we can notice some recurring themes, and develop a checklist that can be applied to any first sentence, to make it clear how a sentence orients and directs the client’s attention.
Now go back to the sentence(s) that you wrote down earlier when I asked you to think of what you typically say to a new client, and examine it, using the checklist as a guide. If you often have the same kind of difficulty with clients, examine your sentence to see if it invites or permits that difficulty. If you decide that you would like to make changes in what you say, write out your new sentence and try it out with clients — first in imagination, then in reality — to find out how that changes what happens in your sessions. Alternatively, you could try out Don’s sentence (#16) or any of the other sentences, to learn how that focuses your sessions, and impacts your clients.
You might choose a different first question than Don’s, or decide on some modification that would be a better fit for your typical client and the kind of change work you offer. The point is not to find the “perfect sentence”; the point is to be aware of the impact of a sentence, so that you can frame your sessions in a way that facilitates what you do, making your work easier. As Don writes, “Our clients achieved better outcomes more swiftly, and we felt refreshed at the end of the day.” I hope this article helps you gain clarity about your own first question, and to what extent it sets a direction that is useful.