The first therapy session can vary depending on what the therapist prefers and what the client needs. Some therapists like to start with active therapy right away, while others begin with a session to gather information.
No matter the approach, the main goals of the first session usually involve building a good relationship, getting permission to proceed, talking about the client's history, and setting goals for what they want to achieve. If there's enough time, therapists might also give homework.
For clients with complicated backgrounds or trust issues, it might take more sessions to build a good relationship and understand their history before doing deeper therapy work. Taking the time to build trust is really important in these cases.
Overall, how the first session goes depends on what the client needs and how the therapist works, but the aim is always to start things off well for the therapy journey ahead.
Building Rapport + Feeling the Warmth
The therapeutic relationship holds a central place in ACT, and embodying ACT principles in the therapy room is a powerful way to strengthen it. When we are fully present with ourselves, accepting of whatever emotions arise, detached from our own judgments, and aligned with our core values of connection, compassion, care, and assistance, we naturally foster a warm, genuine, and open relationship. In fact, simply giving our undivided attention to another person with openness, empathy, and curiosity is therapeutic in itself.
It's helpful to reflect on how we perceive each client: Do we see them as a unique and beautiful aspect of life, like a rainbow, or as an obstacle in our path, like a roadblock? Embracing the uniqueness of each client and appreciating the opportunity to work deeply with them can transform our perspective and enhance the therapeutic relationship.
When clients feel deeply stuck—when they are highly fused with their thoughts and avoidant of discomfort—therapy can become challenging and may even stall. As therapists, it's easy to feel frustrated and judge both ourselves and our clients in these situations. However, it's crucial to apply ACT principles to ourselves by letting go of judgment and approaching our clients with openness, curiosity, and appreciation.
A compassionate and respectful relationship with our clients is vital for effective ACT therapy. Without it, our interventions are likely to fail, backfire, or invalidate the client's experience. Exploring and nurturing the therapeutic relationship is a significant aspect of ACT, and we'll delve deeper into it in a future blog. One essential aspect to remember is ACT's principle of radical equality between clients and therapists—we're all "in the same boat." Like our clients, we therapists also face challenges in navigating our minds, staying present, and living in alignment with our values. Recognizing this shared human experience allows us to learn from and support each other on our respective journeys.
The Two Mountains metaphor, introduced by Hayes, Strosahl, & Wilson in 1999, serves as an effective tool for illustrating the principle of equality in ACT. It's often shared by therapists in the first session to convey this concept to clients.
The Two Mountains Metaphor
Therapist: You know, a lot of folks come into therapy with this idea that the therapist has it all figured out, like they're some kind of guru who's completely sorted out their life. But that's just not the case. It's more like this: you're climbing your mountain over there, and I'm climbing mine over here. From my vantage point on my mountain, I might see things on your mountain that you can't see—like maybe there's an avalanche looming, or a better path you could take, or you're not using your tools effectively.
But let me be clear—I haven't reached the top of my mountain and kicked back to relax. I'm still climbing, still making mistakes, and still learning from them. The truth is, we're all in the same boat. We're all on our own journeys, climbing our mountains until the day we're done. But here's the deal: you can get better and better at climbing, and better and better at appreciating the journey. And that's what the work we're doing here is all about.
Obtaining Informed Consent
Obtaining informed consent in ACT is an essential step, usually done within the first session. My preference is to address this before we're halfway through the session. We might say something like, "There's a lot more I want to learn about what you're going through, but before we continue, can we take a moment to discuss the type of therapy I do and ensure it's the right fit for you? Is that okay?"
When explaining what ACT entails, here are some key points to cover:
ACT is an active form of therapy or coaching. It's not just about talking about your problems and feelings.
We work together as a team to help you create the life you want to live.
A significant aspect involves learning skills to detach from difficult thoughts and feelings, reducing their impact and empowering you to move forward.
We'll also clarify your values: identifying what truly matters to you, the qualities you want to cultivate, and how you want to interact with yourself and others. Then, we'll take action to address challenges and improve your life.
Each session aims to leave you with an action plan—a practical step to actively enhance your life.
At times, I may suggest trying new things that might challenge you. However, you're always free to decline any suggestion.
These points lay the groundwork for the 2 following metaphors that can help illustrate the concepts effectively.
The "Press Pause" Metaphor
The "Press Pause" metaphor is not essential, but it is highly recommend for a couple of reasons, which I'll explain shortly. It's best introduced immediately after obtaining informed consent. Here's how it works:
Therapist: "Can I have permission to 'press pause' from time to time during our sessions? This means that if I notice you doing something that seems really helpful or useful in terms of dealing with your problems and improving your life, I can slow the session down and ask you to really pay attention to what you're doing. For example, I might ask you to pause, take a couple of breaths, and notice what you're thinking, feeling, saying, or doing. This way, you'll be able to see more clearly what's happening, and we can explore how you can apply it outside of our sessions. Is that okay?"
"And can I also 'press pause' if I notice you doing something that might be contributing to your problems or making them worse, so we can address it?"
"And, of course, this goes both ways—you can also 'press pause' on me, anytime you like."
With this mutual agreement to 'press pause,' you now have a simple mindfulness intervention you can use at any point in our sessions. This can help interrupt problematic behavior or reinforce psychologically flexible behavior as it arises.
For instance, if you notice the client becoming aggressive with their words and body language, you could say, "Do you remember you said I could 'press pause' at times? I think this is one of those times it would be useful. Could I ask you just to pause for a moment, take a breath, and notice how you're speaking and acting? Can you check in and see what you're feeling right now?"
If the client suddenly becomes more engaged, sitting up straight and showing interest, you'd want to reinforce this behavior. You might say, "Can I press pause for a moment? I can't help but notice you're doing something different right now. A few minutes ago, you were slouched and distant, but now you're sitting differently and seem interested. It makes a huge difference to me; I feel much more connected with you, like we're really a team now."
This metaphor creates an opportunity to intervene effectively during sessions and strengthen the therapeutic relationship. After discussing the "Press Pause" concept, you can segue into the guitar metaphor, which goes like this:
The Guitar Metaphor
Therapist: "Think of doing ACT like learning to play guitar. You can't master guitar by just thinking, reading, or talking about it; you have to pick it up and start strumming. Similarly, with these new ACT skills, I'll guide you through them in our sessions together, but the real progress comes from practicing them at home. Just like becoming proficient at guitar playing requires practice, improving in ACT means practicing these skills regularly between our sessions. So, I'll encourage you to take these skills home and incorporate them into your daily life."
Wrapping up
In the first session of Acceptance and Commitment Therapy (ACT), therapists aim to build a strong foundation for the therapy journey ahead. They do this by getting to know the client, making sure they understand what therapy involves, learning about the client's past experiences, and setting goals for the therapy.
By taking the time to build trust and understanding from the beginning, therapists can create a solid foundation for the therapy to be effective. Using the metaphors like the "guitar" and "press pause" metaphors are good ways of establishing this foundation.
The first session sets the tone for the rest of the therapy and helps pave the way for progress and growth in future sessions. Good luck on your first session!