Welcome back to Frontiers of Psychotherapist Development (FPD) blog. Today, another snippet from the recently released book, The First Kiss: Undoing the Intake Model and Igniting First Sessions in Psychotherapy. (Available here with various retailers).

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Chapter 4: Avoid TBU (“True But Useless”) Information

A psychotherapist is not an archaeologist. 

In the first session, don’t go digging around for “true but useless” (TBU) information.^⁠1

The Intake Model schools us this way: Step 1: Figure out the “clinical” background, who’s who in the system. Step 2: Develop a rigorous case formulation. Step 3: Slay our clients with our latest evidence-based interventions. 

We do not need to conduct a “thorough psycho-social assessment” before we begin therapy. 

Our urge is to gather all the necessary facts from the person. One eminent psychiatrist once said to a room of more than a hundred mental health professionals during a grand ward round, “we must seek the truth out of our patients.” I gather he was extolling us to become Sherlock Holmes. While his forensic approach appealed to me, imagine if we adopted this idea in our first sessions in therapy. 

Have we earned the license to pry? 

If we start a first session like a truth seeker, we run the risk of three problems. First, as we try to dig the past and gather all the facts, we may inadvertently re-traumatise our clients. For example, I was referred by Benjamin’s general practitioner (GP) to help him with his post-traumatic stress disorder, regarding a significant event of abuse that happened in his teenage years. Even though it was clearly defined as PTSD by his GP, Benjamin wasn’t prepared, nor interested in talking about it in the first session. If I had pushed, insisting that this was the primary concern, I would have caused emotional injury. He might have dropped out from therapy.

Second, even as we attempt to gather all the facts in the first session, even if your client responds to your questions, we may not have consensus to delve in a particular area of their life. Returning to Benjamin, I could have stated that I needed some background information about the past traumatic event, even though we wouldn’t go to work on it immediately (Do you hear TBU?). By doing this, I run the risk of disembodying his experience in the assessment process. Another time I heard a person come out of a session from a mental health centre and saying to her mom in the waiting room, “Why should I come here and reveal my feelings?! What good does that do, opening up old wounds?” She burst into tears. I would speculate that the therapist and client have not yet formed a consensus about what to talk about.

Finally, the Intake Model not only assumes that there are a handful of priorities but it also fails to commit to an effective focus. That is, while we gather TBU, we lose a sense of an emotionally charged purpose of therapy. An Engagement Model develops an effective focus. The sun alone does nothing to a leaf, but when we focus its rays through a magnifying glass, the leaf starts to smoke.

Near the end of the first session, I asked Benjamin, “What are some questions that I have yet to ask you that you deem as important?” Ben said, “I don’t know how to phrase it in a question, but I know that I can’t change what happened in the past… I just can’t seem to make relationships work.” Ben was saying that maintaining relationships is a problem for him, and this source of pain is an entry point for him in therapy. Work with that. Don’t go digging first. If it’s relevant, trust that the issue will unearth itself in the process. It was only in the eighth session that he began to bring up issues relating to the past traumatic events, which was related to his mis-trust in relationships. If I had tried to be efficient and pry further in the first session, he wouldn’t have felt emotionally safe to continue therapy.

Developing an emotional bond is still no guarantee of an effective focus. We need to gain consensus on the process goal (i.e., the agreement on how to go about working through the challenges) and the outcome goal (i.e., what the person ultimately wants from treatment). I recall another client some years back, that we both felt that we had a good connection with each other, but ultimately, it didn’t translate to good outcomes. Upon review, it struck me that I failed to develop an effective focus throughout the first 15-16 sessions!

Resist the temptation of TBU.

Note: 

1. Heath, C., & Heath, D. (2011). Switch: How to change things when change is hard. New York: Random House Inc.