Successful addiction treatment starts in the first session. The minute the patient walks through the door, the process of building a positive therapeutic relationship begins. The stage is set for working respectfully and ethically. The first session presents an opportunity for the counselor to demonstrate the desire to be genuine and intentional in interactions with a patient. Intentionality is demonstrated when these interactions are flexible and client-centered, rather than rigidly based on any one model of care. A counselor’s intentionality is critical, especially in the first session.
Dating back to the 1990s, researchers have studied the patient and therapist factors that most influence the change process. While we frequently hear counselors cite patient motivation as the key factor dictating therapeutic change, the research finds that client factors account for only about 40% of the change process. Thirty percent is influenced by the therapeutic relationship and another 15% is influenced by the expectations that the counselor and patient bring to the start of therapy. Surprisingly, only 15% can be directly attributed to the counselor’s model of therapy and the interventions utilized.1 Given these statistics, it is imperative that addiction counselors recognize the importance of the first session and the role they play in setting the stage for positive outcomes.
The complexity that patients bring when starting treatment and the care required to meet their individual needs influence the process that counselors undertake as they develop a therapeutic relationship. Whether the treatment takes place in a residential or outpatient setting, patients present with biological, psychological, social and spiritual issues that are unique to their subjective experience of addiction and the problems that precipitated their seeking treatment.
There’s a context at this moment in time that’s unique and important. While counselors have worked with similar clinical issues in the past, they have never worked with this client, and what’s motivating that person either to seek change or fight to stay the same.
There is no such thing as an unmotivated client. From the very first meeting, the therapist begins to assess what the patient is motivated to achieve and works to meet that person where he/she is. As most counselors attest, many patients are highly motivated to stay the same. A counselor’s negative response, verbal or non-verbal, to a patient’s motivation in the first session sabotages the outcome of therapy before therapy even begins.
Client history of trauma is another significant factor in the joining process. Fifty to 90% of patients who enter addiction treatment have experienced serious trauma, and 30 to 50% meet criteria for post-traumatic stress disorder (PTSD). The initial outpatient sessions or residential days might be experienced as threatening and might trigger past traumatic memories and elicit traumatic defenses. Hypervigilance emerges as traumatized patients attempt to ensure safety and to maintain some sense of control. From the moment the counselor and patient make eye contact and introduce themselves, the patient’s need to experience the counselor as safe begins the process of the patient assessing the counselor as much as the counselor assesses the patient.
Session's clinical objectives
The primary objective of the first session is to lay the groundwork for a positive and safe therapeutic relationship. Several factors critical to success come into play. The first is the counselor’s ability to be genuine. Being genuine necessitates counselor self-awareness and a desire for emotional and relational coherence.
In the first session, counselors either succeed or fail to present as genuine through the congruence of their verbal and nonverbal communication. Patients are more influenced by counselors’ nonverbal communication, most notably body language, eye contact, and the volume and tone of voice, than by what counselors actually say. Inconsistent messages interfere with their ability to convey who they are and what patients can expect when working with them. One example of an inconsistency might occur when a counselor expresses a full commitment to developing a connected and collaborative relationship, but does so while checking the phone or fidgeting in a chair.
Counselor incoherence can be spotted a mile away. Addicts have lived a consistent life of inconsistency, saying one thing and doing another, which makes them keenly aware of this same process in others.
The second critical success factor in building the therapeutic relationship is a counselor’s ability to remain present throughout the initial session and beyond. Counselors are perceived as present when they are fully focused on the patient, while maintaining a dialogue focused on recovery and healing. Within this process, the counselor must remain grounded in the here and now, confident, non-anxious, and focused on the patient's unique story. Distracted counselors who look at their watch or can’t remember clearly stated details of the story are viewed by the patient as uninterested and unsafe.
The issue of presence is especially pertinent for counselors in the residential setting. Here, the first meeting is too often a brief encounter where the counselor is saying hello while running off to facilitate a group or other treatment activity. Again, the inconsistency of a counselor’s verbal and nonverbal communication comes into play when apologetically promising to meet with the patient later in the day, while leaving to complete other “more important” tasks. This “fly by” encounter creates the unintended first impression of a counselor who is unavailable or too busy to focus on the new patient's needs. Whenever possible, the residential counselor should schedule meeting a new patient when there’s time to be genuine and present.