Practical Questions Beginning Psychotherapy

This article addresses several practical issues related to beginning psychotherapy: telephone contact, the initial session, referral to another therapist, discussion of arrangements, charging for missed sessions, guidelines for the patient and interactions outside the therapy hours. It takes a question-and-answer form, dealing with with questions a neophyte psychotherapist might ask. Although the article specifically relates to treatment that is dynamically oriented, it is also relevant to other forms of psychotherapy.

How Should the Therapist Handle the Initial Phone Call?

The first contact with a patient is invariably by phone. This contact can vary from simply setting up an initial appointment to a prolonged discussion. The therapist can easily answer questions regarding fees, office location, time availability, and experience and credentials. Questions regarding the therapist's comfort and expertise with

certain types of problems, in addition to the type of therapy typically utilized, are also reasonable.

It is usually advantageous for the therapist to be friendly and open, answering relevant questions in a straightforward manner. It is not advantageous at this early time to delve into the reasons for the questions, speculate on the dynamics or make any kind of interpretive comments. At this stage, these types of interventions appear intrusive and are usually not appreciated.

If the questions become more personal, or go on and on, limits need to be set-but in a very tactful way. Phone calls resembling initial sessions are best avoided. Contrary to the expectations of some, lengthy phone conversations are not positively correlated with a potential patient's ultimate decision of whether to undergo treatment with a specific therapist.

If the therapist only has five or 10 minutes when returning the call, it is reasonable to state such at the beginning of the conversation. Sometimes it is appropriate to call the patient back if additional information is desired. For example:

Therapist: Before we start, I do want to mention that I have an appointment in 10 minutes. If we don't finish by then, I'll be happy to call you back. (then, after seven minutes) We are going to have to stop in a minute or two. If you like, we could set up an appointment. Or I'd be happy to call you back if you need more information.

What Kinds of Patients Tend to Stay on the Phone?

Long initial phone questioning is most characteristic of borderline patients. Some of these individuals are preoccupied with searches for the "ideal" therapist. Feeling quite vulnerable to the vicissitudes of relationships, they want to feel as comfortable as possible before the initial session. These patients sometimes look for therapists with whom they feel the right "vibrations, wavelengths or sensations," the ones whom they sense are similar to themselves and the ones who share similar values, philosophy and upbringing. Initial phone conversations can be reflective of these searches. With these individuals, tact and patience is of the greatest importance. Limits have to be set with the patient, but with the utmost skill and sensitivity.

The following comment was made after a 20-minute conversation in which the patient had basically found out all the necessary information and more.

Therapist: I don't want to be impolite, but I do have to go in several minutes. I do think we've covered the relevant questions about psychotherapy. Certainly I will be happy to answer additional questions when we meet. Would you like to set up an appointment?

How Is the Initial Session Structured?

Upon meeting the patient, I introduce myself, invite the patient in, and then say, "Why don't you have a seat." I then pause, allowing the patient to take the lead. If asked for clarification about what to say, I state, "Why don't you tell me about yourself, especially in reference to coming to see me today." I want the story to be presented in the patient's own way; thus, I do not interrupt, except to ask for relevant clarifications.

I am not concerned about obtaining all the details in the first session; rather, I am interested in hearing how patients talk and think, and in learning about their personalities, conflicts, strengths and weaknesses. I want them to feel as comfortable as possible, so that they'll continue the process. With that in mind, I make empathic comments if relevant, and try to maintain a friendly and interested stance.

If a patient's anxiety demands that I ask questions, I do so. Otherwise, I don't interrupt. I am particularly interested in the motivation for therapy. With that in mind, I often ask what ideas the patient has about treatment, what gain is hoped for from therapy, and how the patient thinks the process works.

With about 15 minutes left in the session, I note that there are about 15 minutes left, and that I want to shift focus. I state that although what the patient is saying is very important, I want to make sure that there is time to ask me questions. I find it rather important to make this intervention, because many patients have definite questions they "need" to ask. However, they typically do not ask unless invited to do so, at least not until the end of the hour. Then, either the session has to be extended or the patient leaves frustrated.

What Is the Best Way to Make a Referral?

When making a referral, a common practice is to give patients three names, so that they can interview each and make their own selection. I do not agree with this approach. I do not know how a patient can make a rational decision about which of three therapists will ultimately be best on the basis of one or two interviews.

With the above in mind, I prefer to give only one name. I tell the patient that, although I think that the therapist selected should work out, if there are any problems, to please call me. Before referring, I discuss with the patient the type of therapist desired, finances, geographical location and any other relevant issues. With that information in mind, I select a therapist whom I think will work. Additionally, I find out if the therapist has hours available that are suitable for the patient and is willing to see the referred individual. If the patient is dissatisfied with this referral, I am then willing to discuss the relevant details, making another referral when appropriate. One name, given in this manner, works out the vast majority of the times. If, however, the patient is insistent on getting three names, I go ahead and give them.

What Initial Arrangements Need To Be Discussed With the Patient?

Arrangements that need to be discussed early on include scheduling of appointments, payments, handling of missed appointments, guidelines for the patient and, on occasion, expectations regarding interactions outside the sessions. Scheduling appointments convenient to both patient and therapist is, of course, ideal. Payment arrangements that need to be addressed include both fee and collection policy. Many therapists have some flexibility in their fees, with some ability to make adjustments in accordance with the patient's income. In these situations, frank discussion of the patient's finances and insurance coverage need to be part of the fee-setting. It is important that both therapist and patient are comfortable with the fee.

A usual practice is to bill at the end of the month and collect shortly thereafter. Payment can be due the session after the bill, two weeks later or a month later. Sometimes there is an agreement to wait until the patient has collected from insurance. Whatever the arrangements, they need to be clearly agreed upon. Deviations from the agreement then can be focused on in the treatment hours, as they occur. Charging for missed sessions, guidelines for the patient, and interactions between therapist and patient outside the sessions will be discussed in the final three questions.

Some patients enter treatment with some urgency, in some state of crisis or regression. They are preoccupied with their problems, and want to address them as soon as possible. For these patients, discussion of the above arrangements can be burdensome, seeming like a distraction. For patients in this category, I discuss the arrangements piecemeal, after some of the presenting issues have been addressed, and when the patient is in a calmer state. The patient is then able to approach the arrangements both with more interest and more cooperation.

Should Patients Be Charged for Missed Appointments?

Not long ago, the usual rule regarding missed appointments was for the therapist to charge unless the time was filled. A reasonable addition to this was that, given advance notice, the therapist was willing to reschedule, if possible. Although still reasonable in many cases, this rule appears to be going out of favor. Some therapists have a rather liberal policy of not charging if notice is given a certain number of hours in advance (like 24 or 72). Others do not charge if there is a good reason for the missed appointment. The latter is never a good idea. Illness, car problems, college examinations or other important appointments, although reasonable on the surface, are often used as resistance. Evaluation of the reasons for missing appointments puts the therapist in the unwanted position of an authority figure, inviting the patient to rebel.

The therapist can show some flexibility in establishing agreements regarding missed sessions. I favor telling the patient that my usual policy is to charge for missed sessions unless I fill the time. An exception is that I am willing to reschedule hours, if possible, when given advance notice. I state that I understand many have difficulty with such a policy. Thus, if the patient has any misgivings, I am willing to discuss them.

I do believe that the policy as stated is beyond the usual experience of many. Some patients see it as overly rigid, greedy, one-sided and unfair. With those who are not able to understand it from the therapist's perspective, the policy is not a good one. In these cases, modifications are necessary. With some patients, where I sense that there will be clear antipathy toward the usual policy, I do not bring it up. If and when a problem arises with these patients, I approach it in a flexible manner.

What Guidelines Are the Patient Given?

It is useful for the patient to be given a set of guidelines regarding psychotherapy near the initiation of treatment. These guidelines establish a frame for the therapy, one that can be returned to whenever there is a deviation. A standard presentation that is useful for most patients is as follows:

Therapist: These sessions are yours, to talk about anything you want. It will be up to you to choose the topics. Often there will be topics that are on your mind that you very much want to talk about. At other times, this will be less clear. At times when you do not have topics of pressing importance, it is helpful to talk freely about anything that comes to mind. In fact, whenever you have extraneous thoughts or fantasies, it is useful to talk about them. There are certain thoughts that some people find difficult to talk about and are tempted to omit. I want to urge you to do your best not to omit those types of thoughts. These include thoughts that cause uncomfortable feelings, such as anxiety, anger, embarrassment or shame; ones that you view as silly or irrelevant; ones that you are fearful that I will disapprove of; and any thoughts, positive or negative, that refer to the therapy or to me personally.

Interaction Outside of the Sessions?

Regarding interactions between patient and therapist outside the therapy hours, the general rule is the less, the better. The therapist can make it clear that calls at times of true emergency are welcome and even expected; otherwise phone calls are not desired. Emergencies necessitating calls sometimes need to be spelled out; many so-called emergencies can be easily handled without the therapist. The generalization here is that psychotherapy proceeds best when it is confined to the therapy sessions. If there is not enough time during the sessions, the frequency of the sessions can be increased.

Of course, there are numerous exceptions. Some patients, for example, need very brief occasional contact to confirm the reality of the therapist. Others need various kinds of brief contact to avoid overwhelming anxiety. Under these circumstances, therapist and patient can arrange for limited telephone conversations.

Specific agreements regarding phone calls need not come up at the beginning of treatment, unless an obvious problem is anticipated. Discussion can wait until after the first or even second call. At that time, the rationale for any limits can be stated and discussed. Limits set in a reasonable way can make the difference between virtually no phone calls or daily phone calls. To set these limits well, the therapist needs to have good boundaries regarding the therapy hours, plus the belief that therapy is best carried out when it is confined to well-defined sessions.