Below is an introductory excerpt from the forthcoming book, The First Kiss: Undoing the Intake Model and Igniting First Sessions in Psychotherapy.
Don’t study the end result. Study the first step.
~ Josh Shipp
I grew up as a shy and anxious kid. Though most people see me as a relatively calm person, for the first ten years of clinical practice as a psychologist, right before a first session, I’d get a sick feeling in my stomach. Often, I’d get the runs in the morning. It was a real struggle. The nervousness was as bad as going on a first date. Unlike the low headcount I had in the dating scene, I had to deal with a lot more encounters with new clients, sometimes seeing four to six new clients in a week, on top of an existing heavy caseload. The anxiety was unrelenting.
For the most part, I was working in a mental health institution and hospital settings. I oscillated between two approaches to manage the nerves of first sessions. I either devoured all the person’s past medical records (patients in our hospital were usually seen by a psychiatrist before being referred to us), or I avoided the case files like the plague. For the latter, I reasoned with myself that by doing so I was curtailing biases since the case notes were diagnostic-laden descriptions. Both approaches worked for a while but failed eventually because ultimately, they didn’t address the real problem I was quietly confronting:
How do I engage a person in the first session?
The reason this was a challenge was that I was at odds with the way I was trained. In the traditional pedagogy, I was taught to conduct a thorough clinical assessment. Early in my career, working in a private psychiatric ward, we used to conduct a free intake assessment for outpatients. It was a marketing device. Its purpose was to lure people into our services. That’s not to say it wasn’t effective in helping some people take the first step. This helped many make sense of their problems and engender hope that it could be dealt with by our services. But what I was struggling with was the people who didn’t come back after the free intake assessment. Whatever happened to them? Did they get the help that they needed?
When I moved to work in a large national mental health institution, though there was no “free intake assessment” ploy, the problem was the same. We would run an intake assessment, before the “real” therapy began.
There’s a saying that doubt is a good servant and a bad master. For more than a decade, self-doubt had been my master, and I was the servant. I was plagued by clients dropping out before experiencing any benefit. Because I’ve been systematically collecting outcome data1 early in my career, I began to dig up the dirt. As I analysed my outcomes, I noticed that there were a bunch of folks who came for a first visit and then went off the radar. In fact, I couldn’t even recall who many of them were!
Here’s what I found in my outcomes: In the first three years working in the mental health institution in Singapore, even though my average number of sessions was seven, my mode number of sessions (in statistical terms, mode simply means the most frequent number that appears in the data) was two. This meant that many people were coming for two sessions and then discontinue treatment. This is not to say that number of sessions is the primary metric to look out for. The main aim we should strive for is client benefit. But it’s hard to aim for improvement of client well-being if they aren’t returning for therapy!
Then I discovered something small, but significant. I was not alone in this issue of premature termination. This hidden fact only struck me later in my profession when I began consulting with agencies who were invested in improving their service deliveries and professional development for their staffs. When I looked at their raw outcome data, I noticed that even though most teams have average performance, and also have clients attend an average of four to six sessions (similar to existing research), an often undetected piece of data is that a large percentage of clients attended only ONE session. In my naivety, I was shocked at first. I shared this with the agencies. Many of the practitioners and their management were scratching their heads, given that they were using outcome management systems and had their eyes on the data. It wasn’t their fault. The problem was this: Clients who attended one session only were removed from the dataset, therefore, not on their radar.
This disturbed me. I dug up a study that my colleague Sharon Lu and I conducted in 2009, which examined the impact of employing feedback measures to aid clinicians in an outpatient setting. I reanalysed the data, and this time to no surprise, the same finding emerged. For every hundred clients that are seen, nearly 30 in our business as usual group attended only one session and did not return for subsequent sessions.2
Then I came across one of Michael Yapko’s training, and he mentioned the same statistic in the United States — the most frequent number of sessions attended was one. In the United Kingdom, a national audit called Improving Access to Psychological Therapies (IAPT) programme found that while the recovery rates were close to national benchmarks of 50%, this analysis did not include clients who did not attend more than one session. In fact, out of 32,382 clients, 10,500 (32%) of them had “no evidence” of more than one session.3
I got obsessed; I dug a little deeper. It turned out that one of the first reviews of premature termination in psychotherapy, conducted in 1975, indicated that 20 to 57% of clients drop out of treatment after the first session.4 A more recent study in 2008 estimated that 32% terminated therapy after the first session.5 (A coincidence that the same percentage was reported in the IAPT study mentioned earlier).
A pattern was emerging. So I went back and reanalysed my own outcomes. Somehow, over the next three years in the same setting in Singapore, my average number of sessions was six, but now the majority of clients attended four sessions; an increase of two sessions. When I moved to Australia and worked in a group private practice, my average number of sessions moved to 8.42, and my mode number of sessions increased to eight. The truth was I had no idea at that time what I was doing differently that improved the sustained engagement of the majority of my clients.
This book is my attempt to deconstruct what happened and what I’ve learned along the way.
~~~
It took me several months to reconcile the differences of my first sessions with practitioners in agencies that I was consulting with, as well as determine the cause of my increase in engagement across time. I was sure I wasn’t unique in my ability of retaining clients for more than one session. As I spoke with more practitioners about this, the overarching problem in our field became apparent:
The way we were trained to conduct a clinical intake assessment does not engage clients.
I recalled one therapist telling me about his attempts to run the full Minnesota Multiphasic Personality Inventory (MMPI) at the intake session, so that he can get a good profile of the person. If you’re familiar with the MMPI, you know it can take anything from two to three hours to complete. What is the point of getting a thorough profile of your client if they are not going to continue to work through their struggles in therapy? Clinical curiosity should not be at the client’s expense.
Unplanned termination of therapy after the first session is a problem for both sides. From the client’s perspective, they not only take the steps to make time, effort and money to work on their concerns, but they also have to break through feelings of vulnerability about revealing one’s inner-life to a perfect stranger. From the mental health service provider’s perspective, we’ve lost a client. We’ve dropped the ball. It’s not even about the money, but It’s like a customer entering a home-improvement store, ready to buy a particular piece of equipment, only to walk out empty-handed because you didn’t provide proper guidance in the sea of options.
Some practitioners might raise the people-just-want-fast-food argument, therefore people don’t sustain through the course of therapy. Professor Robert Cialdini offers a useful example of restaurants. He says that restaurants do better when they give their customers something to eat (e.g., yoghurt) when they are waiting in line. “Economists say ‘Don’t give them food.’ Psychologists say, ‘Give them food because you’d give them what they need.’”6 While it sounds counterintuitive giving customers something to eat for free while they are waiting, reducing their hunger pangs fosters a higher satisfaction and pleasurable dining experience. Giving customers a “pre-entree” is not the same as serving them “fast food”. It engages the person.
Instead of just “taking” information, we need to give our clients something to hold on to in the first session as well.
My outcomes data alone wasn’t helping to provide a better understanding of the problem at hand. I began to re-examine my video recordings of my first sessions (see the chapter Recording Your First Sessions). How did I subconsciously unschooled myself from a typical intake assessment?
It became apparent when I compared my recordings with my supervisees’ recordings of their first sessions. It dawned on me that the way I ran first sessions was exactly the opposite of what I was taught to do. Somehow, I deviated from the traditional script. Instead, I pursued a path to find a way to amplify and magnetise each person in therapy so that they would feel the pull to want to work through the distress that brought them to see me.
~~~
Thanks to the many wonderful mentors and teachers I’ve met on my journey, I was able to unhook myself from the notion of particular ways of doing therapy. I had to find my own way. I believe we all have to find our own way.
This short book is a cumulation of some trials and many errors. It is an unabashing “how-to” book, based on key principles of engagement. I’m not suggesting that this is “the way.” I’m aware that I’m somewhat playful in my engagement style, and I generally eschew sticking to a particular treatment modality. That said, I generally think in systemic terms, and aspire to make sessions more experiential.
I wrote this book for two reasons. First, I wrote this to clarify what I think I know. As I do that, I’m trying to weed out stuff that isn’t necessary in a first session. Ask any filmmaker and they will tell you that the role of an editor is a crucial one. They take reels of footage, splice and sequence them in a way that creates an impactful scene. I strive to do this as I write. Many initial ideas for this book didn’t make the cut.
Second, my aim for this book is to provide an alternative voice. I’m aware that many books on the first session in psychotherapy exist. If you want something more comprehensive on dealing with dropouts, I highly recommend you check out Joshua Swift and Roger Greenberg’s (2015) excellent book, Premature Termination in Psychotherapy. On the topic of first sessions, I recommend Robert Tabibi’s (2016) The Art of The First Session. It’s more thorough than this book. My only credential for this book is that I offer a different perspective. As you will notice, I’ve grafted many ideas outside the world of psychotherapy.
Based on 13 years of collecting my outcomes data for every session, I’ve somehow managed to improve my engagement levels with clients.
I hope when practitioners read this book, they either apply some of these principles in their own fashion, or come to disagree with the ideas. Please, honor any dissenting voice in you. For example, some might still vehemently swear by conducting a thorough assessment before beginning any formal treatment process. If so, I love to hear from you. (Remember, I’m a student, and I don’t claim to be a pre-ordained master therapist).
David Foster Wallace said that good nonfiction was a chance to “watch somebody reasonably bright but also reasonably average pay far closer attention and think at far more length about all sorts of different stuff than most of us have a chance to in our daily lives.”7
Borrowing from chess prodigy turned martial arts expert, Joshua Waitzkin, this book is about “working on the micro to get at the macro.” In other words, one of the key ways to learn is to shine our magnifying glass on specific aspects of the clinical work, deconstruct it, study it, and find ways to make the first session count, like your first kiss.
For more Information on the book, Click HERE.
Notes:
1 I was first introduced to doing this in 2004 when a friend of mine shared this book with me.
Duncan, B. L., Miller, S. D., & Sparks, J. A. (2004). The heroic client: A revolutionary way to improve effectiveness through client-directed, outcome-informed therapy (rev. ed.). San Francisco, California: Jossey-Bass Inc.
For a good pioneering example of collecting client outcomes in private practice, see the late Paul Clement’s work below. He has been publishing his outcomes for the past 40 years. Clement serves as a true inspiration to all of us.
Clement, P. P. A. (2013). Practice-Based Evidence: 45 Years of Psychotherapy’s Effectiveness in a Private Practice. American Journal of Psychotherapy, 67(1), 23-46.
Clement, P. W. (2008). Outcomes from 40 years of psychotherapy in a private practice. American Journal of Psychotherapy, 62(3), 215-239.
Clement, P. W. (1994). Quantitative evaluation of 26 years of private practice. Professional Psychology: Research and Practice, 25(2), 173-176. doi:http://dx.doi.org/10.1037/0735-7028.25.2.173
2 Chow, D. L., & Lu, S. (2015). The use of routine outcome monitoring in an asian outpatient psychiatric setting. Paper presented at the World Federal of Mental Health., Singapore.
3 Mander, H. (2014). The impact of additional initial face-to-face sessions on engagement within an Improving Access to Psychological Therapies service. The Cognitive Behaviour Therapist, 7, 1-8. doi:10.1017/S1754470X13000007
4 Baekeland, F., & Lundwall, L. (1975). Dropping out of treatment: A critical review. Psychological Bulletin, 82(5), 738-783.
5 Barrett, M. S., Chua, W.-J., Crits-Christoph, P., Gibbons, M. B., & Thompson, D. O. N. (2008). Early withdrawal from mental health treatment: Implications for psychotherapy practice. Psychotherapy: Theory, Research, Practice, Training, 45(2), 247-267.
6 Interview with James Altucher #184: http://traffic.libsyn.com/altucher/JAS-184-RobertCialdini-v01-FREE.mp3
7 The quote from David Foster Wallace was cited in
Kleon, A. (2014). Show your work: 10 Ways to share your creativity and get discovered. United States of America: Workman Publishing Co, Inc.
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