Texas Counselors Creating Badass Businesses

6. What Makes a Great Intake Session? These 3 Things

October 27, 2022 Dr. Kate Walker Ph.D., LPC/LMFT Supervisor Season 1 Episode 6
Texas Counselors Creating Badass Businesses
6. What Makes a Great Intake Session? These 3 Things
Show Notes Transcript

Becoming a successful counselor is often a matter of bringing a few key skills together. One of them, the intake session, is as vital as it is scary to some people. So how do you get to the point where your words work for you instead of against you? Today, I’m talking about three strategies to make it easy for us to combat first session anxiety, know exactly what to say to help our clients co-create solutions with us, and stop playing the pursuer-distancer game once and for all. I've helped my students and interns learn these exact same skills to help their clients. You’ll hear all about how we do it in this episode! So what is the basic structure that a great first session follows? How do you connect deeply with your new client? What is the best tone to use in your first session, and how do you practice it? Listen in on this game-changing episode for answers to all of that. More at https://katewalkertraining.com/counseling-techniques-and-skills-first-counseling-session-tips/

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 I’m so glad you guys are here, and today I’m going to take you through the steps to make a great intake session, or to have a great intake session. And so what I expect to teach you may be different from what you get out of this, so here’s what I’d love for you to get out of this today: the why. 

Why do we even need to talk about the steps for a great intake? I mean, right, Kate, it’s just this piece of paper, I’m supposed to go through it, and at the end, give the client a diagnosis. Wrong. No. So by the end of this, I hope you understand the why. I hope you understand the structure. And I hope you understand what to say. I really want to give you those specific steps.

Let’s get started. So, when we talk about the why – why do we do an intake session? And we think okay, so it’s definitely so I can get information. You know, I know a lot of schools that will go mail that information to the potential client – and when I say “school,” I’m talking about graduate counseling programs who have students in their supervised practicum, and they want the students to spend time counseling. So they’ll mail that intake paperwork to potential clients, or nowadays, have it online, and they’ll just expect that paperwork to be completed when they come in. And, you know, for me, that’s a missed opportunity. 

When I teach graduate counseling classes, I always do – especially if it’s online or there’s some kind of a hybrid or an online component, I’m going to ask my students to do a getting-to-know-you assignment. They hate it. They hate it because – so many reasons, but I do it for a couple of reasons. Number one, I do want to get to know my students who may live far, far away from me and it’s virtual and they won’t really get to know me. But I also want them to get used to the technology. So I make them – I force them – to create this video where they are telling me the answers to these questions. So the questions are usually: Tell me something about you; Are you already in the mental health field? What’s something that scares you about counseling and becoming a counselor? What are some things that scare you about this course? And what are two or three things you want to know about me?

Over the years – I mean, I’ve been doing this since 2007 and asking these same questions – a lot of things change but one of the things that stays the same is the students’ fear of harming the client. They are terrified they’re going to say or do something that causes harm. So, yay, because as professors, we’re really pounding it into them that ethics are important. You must have skills and you must study your theory and do good supervision and good work, but the this other piece is, for example, if I have a client who comes in who is suicidal, what if I say the wrong thing? If I have couples who start fighting in front of me, how do I stop that? If I have a critical incident, like someone is in session and they’re having a heart attack, what do I do? So the fears surrounding that first session, that counselor anxiety over what do I say? What do I do? 

I want this to alleviate some of that fear. One of the things I shared today in my email was my own struggles with anxiety. I’ve shared with you guys before; I’m a musician and I originally got my degree from the University of Texas at Austin in music. So I started out literally as a bass major and I can remember having to do auditions and juries. Basically to get a grade, you had to play for the faculty, and I can remember forgetting how to play the bass. I had to do an audition, or I chose to do an audition for the Austin Symphony. Totally forgot how to play bass. My hands were sweaty, I couldn’t breathe, thought I was going to throw up. So performance anxiety is real, and I know you guys know that. So you may see me on these videos or you may see me teaching a class or giving a presentation and I had to go through a process to get to a space where I could do that. Yes, I still get butterflies, but…I still get nerves. It’s not easy.

So when I have a new client, especially if it’s a couple, I’m always thinking through, okay, what do I say? What do I say? What do I say? What I’ve come to find out in my research and through experience, it’s why – why am I asking these questions? Why am I having this first session? Why do I want these people to come in and talk to me? In other words, it’s forcing me to think of what is my end goal? And if you’ve never watched Simon Sinek’s TED Talk on Finding Your Why, what you discover is once you find your why, the what and the how just seem to flow. And that, in itself, is an anxiety conqueror – knowing your why.

So when I say in the title of this, it’s not about the diagnosis, I feel like sometimes we do our students a disservice because we’re putting so much emphasis on the diagnosis. And that’s important, don’t get me wrong. This isn’t an either/or or black-and-white issue, especially with managed care. You don’t get paid if you don’t have a diagnosis, it’s the medical model. The insurance is asking, why should we pay you if there’s nothing wrong? Because something is wrong if there’s a diagnosis, and if there’s nothing wrong, why are they going to counseling? 

So I’m not saying the diagnosis is unimportant. The why, for the first session, though, is rapport. It is rapport. It is in order to collaborate with this new person who just met you so that they buy into the process of doing therapy along with you. So one of the things I wrote about in a blog I did recently was marriage and family therapy extraordinaire, founder, guru, Carl Whittaker, the father of experiential family therapy, said – and I hope I get this right, he said, “You, the therapist, must win the battle for structure. The client must win the battle for initiative.” So it’s like what we tell our students: you should never work harder than your client. In that first session, if you’re just focused on going through the questions as quickly as you can because your manager, or your supervisor, said you have to get through that document in 50 minutes, maybe 90 if you’re lucky, because we’re only getting paid for 50 minutes, I believe you’re really wasting an opportunity to get some buy-in from your client. 

And every profession has to have buy-in. I don’t care if you’re a dentist or you’re a nurse in a chemo lab at MD Anderson. If your client isn’t buying into the process, that’s not going to help anyone, especially your client. And the example I give is, if you’re going into your dentist with a toothache and you’re walking in and they just grab a drill and start drilling on you, you’re going to run, because you don’t want dentistry just done to you. Even the dentist knows you must buy in, you must collaborate with the process. They may look at you and go yeah, it looks like you have a toothache. Is it okay if we do some x-rays? You have to nod, you have to agree: okay, go on, let’s do some x-rays, come back and sit in the chair. Yeah, it looks you you’ve got a cavity, but we want to look around in there a little bit. Do you mind if we poke around in your mouth a little bit? You have to nod; you have to give consent: okay. You’re now collaborating; you’re part of the dental team. They get in there and they poke around: yep, definitely a cavity. Sit down. It looks like it’s going to cost about $300 and we notice you don’t have dental insurance. Do you want us to go ahead and do it? Or do you want a payment plan? Or would you rather that we refer you down the street to the dental college? They can do it for free. Again, you are part of the process. You have to provide buy-in in order for the dentist to dentify you, to do the dental to you. Right?

As counselors, we’re not counseling. I feel like that’s a misnomer. We are creating a space, we’re co-collaborating on solutions. We are creating a space of healing along with our client. Even medical doctors know that; they’re not doctoring you. They are working with you to create a treatment plan that results in you feeling better. And so as a counselor, especially brand new, you’re a grad student, you’re about to bridge over to being an LPC Associate, you’re having first session after first session after first session, you feel that counselor anxiety coming up, I want you to stop and think: why am I doing this? Not why are you entering this career and all that stuff, that’s another podcast, that’s another episode. I want you to think: why am I doing this? What do I hope to happen at the end of this session? And I hope that’s what I’m giving you right now, the answer to that why. You’re hoping to have buy-in, you’re hoping to have collaboration.

So when we think about that, next is structure. Structuring this session is very specific for me, and this is what I teach my supervisees, my interns, my students, and that is to, of course, warmly greet them, and if you’re doing this on video, physically what I do, it’s like what my daughters’ volleyball coaches used to tell the girls: fix your face! Because they might be coming in off a hard game and they’re coming in and their faces are doing this, they’re like, fix your face! This isn’t the same as “smile, you look pretty when you smile.” I’m talking that when you’re about to go on camera with a new client, light up. There is a meme going around on Facebook that’s like two pictures of a little boy and the first picture is “the picture of my son when I tell him to smile” and then “the picture of my son when I tell him to say ‘poop’.” So the picture when they say to smile is kind of a toothy, no joy grin, but when they say ‘poop,’ this little boy’s face is lit up. And you know, if you have an eight-year-old boy or have ever known one or met one, that is a fact. Say ‘poop,’ they will light up. 

So before you get on camera, what do you have to say to yourself to light up? When you light up, the mirroring neurons in your brain talk to the mirroring neurons in your client’s brain and they light up. So now we’re lit up, right? Because remember, your goal isn’t just to get information so you can submit a preliminary diagnosis to the insurance company and make sure you get paid in less than 55 minutes. Your why, right now, brand new, is I must invite my new client to co-collaborate so we can create solutions together in this beautiful thing called counseling. So light up, friend. Hey, here we go. Hey, nice to meet you, I’m so glad that you’re here. Here’s what’s going to happen today. Oh, isn’t that audacious? I’m taking over because I’m going to win the battle for structure.

Here’s what’s going to happen today. I’m going to ask you a lot of questions. In fact, it’s going to feel like an interview. At the end of the session, I’m going to give you two or three directions that we can take if everybody agrees to go forward – and I use the term ‘everybody’ if I’m working with couples or families. If everybody agrees to go forward, then I will give you something to read, write, look up on the internet. The second session, we’ll course-correct based on your feedback. And by the third session, you’ll have an idea if working with me is going to be a good fit. You’ll have some coping tools and some good psychoeducational resources.

Do you see what I did there? I told them the treatment plan and I don’t even know what’s “wrong” with them. Because remember, my why just shifted. My why just changed. I’m not trying to diagnose, figure out the problem – in other words, shrink my world. I’m trying to collaborate with this person I just met who’s so lovely and so brave that they took the step to come to counseling instead of just cope one more day with their pain.

So here I am with this amazingly brave, strong person who has appeared on my doorstep or at the other end of my camera, and I am so excited to get to know them so that I can give them some idea of what treatment options could be. Because even if I’m a dentist and I know that this person has a cavity – I’ve seen the x-rays, I’ve poked around in their mouth, I still must invite them to collaborate with me, to keep coming back, to keep co-creating with me. So what I say is important. And I talk about this more in other podcasts and YouTube videos, this idea of letting the client know what to expect. Of course, that means you have to know what it is that you do. You have to really understand what it is that you do and why it works and how. So knowing what to say, even if you just regurgitated what I just said: here’s what you can expect, here’s what’s going to happen next, by the third session you can expect this. Right? 

So now you have your why. You understand what you can say. And now, it’s down to, okay, so how do we structure this? And when we think about how do we structure, of course it’s going to be different when they’re in front of you versus whether they’re on the camera. You may decide to – I do a little cheat sheet when I’m on camera, especially when I’m with couples, I’ll have a sticky note in front of me where I will have their names, because I say names. It’s very important to me that I get their name right.

True story, when I was first starting out seeing couples, they were coming in for an affair, and I literally called one of the partners by the affair partner’s name. They did not come back. That was a horrible faux pau. I owned it. So get the cheat sheet.

Even if you’re face-to-face, I’m a proponent of having the notes on your lap. I like to take notes while I talk with people. That’s part of my process. Because when they say something, I write. When they say something, I write. Sometimes when they say something, I don’t write. So already, I’ve got them curious about the process. They’re going, why did she write that down, but she didn’t write this down? They’re collaborating; they’re interested.

So the structure is so important. I used to teach – also, we had this office with a really long hallway, so I would teach my associates, or interns at the time, how to greet them, how to walk slightly in front of them, how to keep it light on the hallway walk, don’t ask them about the problem, ask them about the weather. The structure is then, invite them into your office. Also, the first session is a great place, especially if you’re face-to-face, to start training your clients when the end of the session happens. And I’m going to tell you why. Something magical happens once you train your client. And when I say ‘train,’ I’m not being disrespectful to our client, it’s that inner kind of circadian rhythm of when an hour is up, and I know some folks, they’ll hide a clock under the couch, or I used to have a clock behind my head so I could see the time and my client could see the time. We had two chairs. So we had the therapy chair, where I’m talking to my client, and then there was the chair where I would write the receipt and get the billing information. So when I saw there were about two minutes left in the hour, I would stand up, even if I’m still talking, and I would walk to the other chair. 

With virtual, it’s a little bit harder. So one of my behavioral cues now is put on my glasses. When I put on my glasses, that means I’m going to look over here and I’m going to find another slot for their next appointment. So those kind of physical cues, like I said, something magical happens face-to-face. This is funny, I used to tell students this – it used to be that I was like, oh my gosh, I’m getting so good at this counseling thing! It seems like everything seems to wrap up so nicely by the end of the hour. No, what was happening was my clients started understanding that the session was almost over. They were wrapping themselves up. They were starting to wrap up and draw conclusions and set their own homework and what they wanted to accomplish by the next session and if they wanted to come back. It had nothing to do with me.

That’s what I mean – when you really start to understand this idea, new counselor, the weight of the world is not on you. This isn’t about you having to have all the right answers and do all the right things. Yes, we are training you to make critical decisions in secret, right, nobody is watching, under duress. That is the nature of supervision, that is the nature of our profession, we are doing all of these things without observation, and you do have to get it right. But/and, your client is there to collaborate along with you. And if you start with this very, very first session, by setting the structure – winning the battle for structure, having in mind what you’re going to do, what you’re going to say from the very, very beginning, then helping your client understand what to expect at the end of the first, second, third, fourth session, and then inviting them to collaborate with you on that journey. 

I do something called a three-point wrap-up at the end of my interview. So I’ve got the piece of paper in my lap, I’m asking questions, and at the end, I’ll say something like, “well, here are three things I’m hearing.” And I usually tell them something about lifecycle stage. You know, with couples, most fall under – or go into distress – around the time that they’re launching kiddos. So when I’m listening to you guys give me this interview and you’re giving me this information, one of the things I noticed is that you just launched your last kiddo, so what you’re going through is very, very normal. So I give them lifecycle stage in order to normalize the distress that they’re feeling. 

Two, I give them some information about stress. Stress impacts problem-solving, period. Anxiety goes up, cognition goes down. It’s why pilots have checklists. So if I’m working with individuals, they can take a big sigh of relief: well, I have been under a lot of stress lately. Wow, okay, this stuff that I’m going through with my teenager, it is impacting my work. Oh, okay, that makes sense. Your clients take a huge sigh of relief because it makes sense. 

And then I wait until the third point in my three-point wrap-up – and remember, three points is arbitrary. I just like the number three because it’s easy to remember and it’s easy for my clients to remember. The third point is usually their presenting issue, what they brought into me. And so I talk then through okay, you’re here because you’re not sleeping. You’re here because you’re having problems with your kiddo. You’re here because you had an affair, or you got arrested for a DUI. So now, we’ll talk about that. 

But what I’ve done is I’ve given them two other points to let them know, you know what, they’re okay. They’re just like the rest of us humans. They’re struggling. They’re impacted by life. Right? If I did it the other way around and I said, well, it looks like you’re suffering from MDD and GAD with a touch of panic disorder, boom, boom, boom. Right? That’s deflating. Now, if I was the dentist, this is where the parallels end – if I’m the dentist or the ER doc, yes. Give me the problem first. Don’t tell me how my leg is broken because I was a bad driver. Don’t tell me whether my leg is broken because I didn’t wear my seatbelt. I want to know the diagnosis. Get me to the x-ray. Give me the medication. Make the pain stop. 

But remember, in counseling, we’re creating buy-in in a different way. We have to do it by winning the battle for structure, letting the client win the battle for initiative. And the way that we do that in the very, very first session is by letting the client know what to expect and then giving them what they expect. If you said at the end of the first session that they’d have some directions to take and you’d give them some things to read or write or look up, then do that. If you change directions and you follow them down the rabbit hole and you start getting into this battle for, this is why counseling should happen and you know the judge told you you had to be here and you know your mom says you have to be here, now we’re in something called a pursuer-distancer dynamic. And that pursuer-distancer dynamic never works. Google that. Pursuer-distancer dynamic. But you’re the expert, you’re supposed to be aware of that. 

So new counselor, remember, winning the battle for structure means you’re going to offer them the three-point wrap-up. You’re going to offer them the second session and the third session. And they may take you up on it, and they may not. And that’s okay, which is why in counseling, I never recommend you build your practice on a census. Because that client has the right of refusal. They have the right to say no. And yes, it’s happened to me. Oh my goodness.

So here’s what I’m hearing. The lifecycle stage. And I deal with couples, so it’s always two people in the room. “Honey, do you think it’s lifecycle stage?” “Nope, I think we’re good.” Okay, what’s your second point? Stress? “Honey, do you think it’s stress?” “Nope, I don’t think it’s stress.” Okay…three? The affair? “Well, honey, I think we’re kind of over the affair. Don’t you think we’re over the affair?” “Yeah, I think we’re over the affair.” So, boom, three strikes. 

Sometimes, I strike out, and the clients, perhaps – and this is the funny thing too because we never know why our clients come in – perhaps they were coming in to see if counseling was something they even needed. Remember, as a counselor, we’re not competing against other counselors. We’re competing against our clients doing nothing. And nothing isn’t always a bad thing – nothing just means coping another day. If couples are doing great, they just want to come to counseling to see if it can help and they get to the end of that first session and they’re like, “Nope, we’re good,” then hallelujah! Good job! Go you! You’ve just helped them make a decision that will work for them. And they’re not going to forget you. They’re going to remember that you provided a structure, you got to know them the best you could in 90 minutes or an hour, and you offered them some directions they could take and they’re free to come back.

So the first session doesn’t have to be about having all the right answers. The first session, you are establishing rapport. You’re working on building that collaborative nature of doing counseling together by the structure you create and the words you say so your counseling client agrees to come back and work a little bit more and a little bit more and a little bit more. And then one day, if they don’t come back, you know what? Maybe things got better.

Alright, I’m Dr. Kate Walker, thank you so much for watching today. I will watch the threads and hopefully you guys can give me some feedback on this, otherwise, this will go into your Step It Up Kate Walker Training Profile. Alright guys, see you soon.