Tips for nailing the first three therapy sessions (with Marie Vakakis)

[00:00:00] Bronwyn: Hey, mental workers, you're listening to the Mental Work Podcast, your companion to early career psychology. I'm your host, Dr. Bronwyn Milkins.

And today we are talking about how to structure therapy, particularly the first three sessions. The reason why I wanted to do an episode about this is because I think it's something that early career psychologists just often struggle with. What we know from research studies is that dropout rates range from 20 to 47 percent within the first three sessions of therapy. That's a lot of folks who drop out of therapy who really wanted help.

So I think it's really important to make sure, A, that early career psychs are confident and they feel good about doing the first three sessions and B, that clients can get the help that they really need.

So here to help us unpack it all is our wonderful guest Marie Vakakis. Hi Marie.

[00:00:55] Marie: Hello.

[00:00:57] Bronwyn: Marie is an accredited mental health social worker and a family and couples therapist at The Therapy Hub. And Marie, could you please tell listeners something that your colleagues would be surprised to know?

[00:01:09] Marie: Well, I think when people hear how much study I've done, they assume that I just went straight from like school to uni and just kept going. But I actually took a gap year between high school and uni and I went and got a job teaching English in Ecuador. So, I knew no Spanish. I was left when I was 18, turned 19 on, on route. Um, and Got a job teaching English and did that for a good half a year and then came back and studied.

[00:01:39] Bronwyn: Wow, that's so cool. Did you pick up any Spanish?

[00:01:41] Marie: Little bit. That was, um, I lived with a family who spoke no English, so they were really cute and put post it notes everywhere of what all the different things were called and, um, kind of would structure the conversation in a way that would be like, can you please pass the salt? Like, they would be really slow and try and, like, get me to learn the language and it was really lovely.

[00:02:02] Bronwyn: Oh, that's really sweet. That is so cool. It sounds like a really enriching experience.

[00:02:06] Marie: It was really fun.

[00:02:08] Bronwyn: Cool. Thank you for sharing that. Okay, Marie, let's set the stage for this. So I thought what we could do is kind of compare and contrast between us. So I'm interested to know how you go about setting up the first session, what you think really helps retain clients in that first session.

[00:02:30] Marie: I think, um, I don't do it, all the time, very perfectly. But what I'd really try and do is talk about talking. So really spending some time asking someone what their expectations were. Why therapy? Why now? We talk about the consent form, I ask questions, talk about the cancellation policy, um, every, every part of that. So really sort of trying to explain how I work and how I might work with them, how long it might take to see change. Like it's really structuring all of that.

So like in the couples therapy episode we did, I know a lot of people work in different ways with couples and, that can be part of what creates confusion. If someone's like, Oh, I don't know what we're doing and it didn't work. But if I sit down and say the first four sessions is just an assessment, it can adjust their expectations. So they're not walking out thinking, she just listened to us argue for an hour. When actually that's one of the techniques is we let them argue and we take notice of the pattern of conflict, and then we look at that later on.

So, it's, it's being clear in how I work, how I might work with that presenting issue and then finding a way to communicate that and kind of prescribe a, like a dosage of treatment essentially. So this is what the frequency in which I would need to see you. Um, so really setting it up from the start around all of that.

[00:04:05] Bronwyn: Mm, and can I clarify, so do you have like a spiel at the start where you lay out these expectations or does this information arise kind of naturally throughout the conversation?

[00:04:19] Marie: It's a bit of both. So I have a checklist. I started off with a checklist and now I have a bit of a script and then sometimes it just sits in my head, but I really do have a bit of a spiel of I introduce myself first, like my remind them of my name, tell them my qualification, give a little bit of info about how I like to work. Um, I'll ask for permission to, you know, like, and I just want to go through, make sure I've got all, you know, if I had paperwork, like, check all of those things and then explain, I'm going to spend a little bit of the session just trying to understand what's brought you here. So even in that, I would explain that that's what we're doing. And then I usually stretch it over maybe two or three sessions.

So depending on the person, if they've been, you know, been into a lot of therapy, like there might be adjustments, but I'll make sure I come back to some of those things and say, and I just want to, you know, we didn't touch on it last session.

I want to go through our cancellation policy and make sure these things are clear for you. So I do stretch it out over probably two or three. But I do have kind of a set number of things I want to, to kind of cover.

[00:05:24] Bronwyn: And is there anything else that you think might be helpful for early career therapists to know about structuring the first session?

[00:05:33] Marie: We might be very clear about what we do, what modalities we use, but for most clients, it's completely foreign. And even for me, when I've gone to see therapists as a client with different, who practice different modalities, I've been really at times disappointed, frustrated, annoyed or even angry at the way they did things because they don't explain it. So it's really thinking about it's good customer service and it's those common factors like the relationship between you is going to be the biggest predictor of a good therapeutic outcome.

[00:06:07] Bronwyn: Yeah, I think it's, um, it's really interesting that you share that because I do do a spiel at the start and it kind of sounds like we have similar approaches. I do tell clients what the purpose is of today, what they might get out of it by the end. So I'm usually like, by the end, we should know a little bit more about what's bringing you here and how we might be able to work together.

And so I set that up, that expectation, and then I let them know that I'll be asking lots of questions. You have the option to pass if you don't feel like going there, like we just met. People usually find that it's a helpful process and I, sometimes I give them a little bit more information depending on their presentation. So if they look really nervous, I might notice that and be like, it's very normal to feel nervous. Um, that's all right. We'll, we'll take good care of you. Like that kind of thing. But it's striking that I've never had this with another therapist. And I was like, am I doing this? Like, am I doing the wrong thing here? Like, why doesn't anybody else do this?

[00:07:03] Marie: But I don't, I think it's wrong not to because You don't know what you're going in for. So if someone approaches not to talk about that stuff, I think they still should overt that. They should say, I just launched straight in. So let's, let's launch straight in and let's see what comes up, and if you have questions, ask. Like if they give you no boundaries and no parameters and no idea of what to expect, what you can expect of them. Like it's, it's, not a recipe for success.

[00:07:33] Bronwyn: Yeah, I agree. And I think the research really backs that up, that it's really important to give clients that socialization to therapy. I mean, that's the, you know, the jargon word, but it is giving them the safety and structure and like, this is my role and this is what I'm hoping that we can have from you.

And when you think about it, like a lot of our clients come to us and they might be experiencing depression or anxiety. They might not be feeling great about themselves, might be quite anxious about therapy. I, I think this helps. them by giving them a bit of, um, expectation and structure. What do you think?

[00:08:04] Marie: I think that, and it also role models a skill that most people don't have. So you get to talk about clarity and not be avoidant. Like I have some people who are like, I didn't even want to take their credit card details down. I'm like, well, then you've got some shit you've got to sort out about money. Cause you know, you really need to role model some of that, a level of humility, an accountability, being authentic and what you do and how you do it. It doesn't matter as much as telling them, this is what I do and how I do it.

[00:08:37] Bronwyn: Yeah. And maybe adding to that as well. I don't know whether this is people's stuff, but, you know, how therapy works in reality compared to Hollywood, I wonder if people like comparing it to stuff they see in movies or something where it's like the therapist has this insight every 10 seconds and then the client is healed after a session or something. I don't know.

[00:08:56] Marie: God, I don't know what you're talking about.

[00:08:58] Bronwyn: Okay, sure. Yeah.

[00:08:59] Marie: Look, and that, and that's part of it. That's, that's the stuff we need to myth bust and normalise and saying, this is what you might've seen. Uh, I, This is how I work. And I think about any service that I've had where I haven't felt it's been a good service, it's always been around expectations not being met. And that's really important.

You know, if you take your car to a mechanic and you think you're just getting it serviced and then they fix all these other things and you get a few thousand dollar bill, overwhelming. But the same could go as if you took the, took your car there and they noticed something was broken, but didn't mention it. And they just did the service and just expected that you were going to take it to somewhere else to notice that, then maybe something drastic could happen. And you're like, hang on, why didn't anybody tell me this thing needed to get fixed?

So it's really around someone saying, this is what we can do. This is maybe what the time allows. This is my skillset allows. If I notice these other things, I'll let you know. And then you can choose to either take it to somewhere else, or I can give you a quote and we can book it in front, like whatever the process is, is being really clear about that. Cause nobody likes to feel stupid and I don't know about you, but no one, I don't even like going to the dentist thinking I'm just getting a clean and I come back with, you know, hundreds and hundreds of dollars. And I'm like, why couldn't you say you need this? This can wait. Like if you feel pressure and under the spot and someone's got their fingers in your mouth, it's really hard to talk about that stuff.

[00:10:28] Bronwyn: It is. No, I agree that it's, it's part of doing a good service. If you think of it that way, it's really handy and reflecting on how we feel when we don't get good service in other areas, like helps us empathize with how clients might be feeling.

I find that educating clients around the process of therapy really helps as well, because sometimes they can have unrealistic expectations about how fast therapy is going to go. So I have had people come to me and an expectation was that this will only take two sessions. And the thing that I'm hearing from them, certainly in my opinion, opinion is not a two session thing.

So orienting them to therapy, this kind of thing takes time. I hear that you want some immediate relief. We can certainly talk about some strategies next session or ways of dealing with this in the immediate, but this might be a long term thing. How does that sit for you? I find it's really good to have that, that open discussion.

[00:11:19] Marie: Yeah. But it's also informed choice, like how can somebody have informed decision making if you're not informing them of what that is?

[00:11:29] Bronwyn: Yeah. Cause then they'll do the thing that, I mean, you just mentioned and they'll walk out and they'll be like, she didn't fix me after two sessions. And it's like, and I didn't tell her that, so of course she's going to be upset

and angry.

[00:11:38] Marie: Or how long, why do I have to keep coming back weekly? And then the therapist might be like, well, I keep booking weekly appointments, so I guess I'll keep serving them. And it's, no one's really clear about where the work's going.

[00:11:48] Bronwyn: Absolutely. So maybe we can expand on that with, what do you do at a session two? I'm interested with how you start off a session two, actually.

[00:11:58] Marie: This is funny because I was talking to, I had a peer supervision group, uh, this week and we all had very different ways of doing this. And what someone was like, Oh, I do this. I'm like, as a client, I hate that.

[00:12:09] Bronwyn: Oh, what was it?

[00:12:10] Marie: Um, she just welcomes them in and just sits there and looks at them. Yeah, that was my response!

[00:12:18] Bronwyn: But some, people love that.

[00:12:19] Marie: And I told her what I do. She's like, oh, I hate that. That's too much work for me.

[00:12:23] Bronwyn: Oh, that's interesting.

[00:12:24] Marie: Yeah. I usually check in, like, how was your day, week, commute, getting here, school, whatever. If I knew something particular had been happening, I'd be like, oh, how was... Sometimes at the end of the session to ground someone, I might ask them about, you know, what are you doing on the weekend or, you know, anything planned for the long weekend or what's on like, so if they've given me something to kind of go with, I'll be like, well, how did that go?

I might ask them if anything, was there anything I said last session that really you mulled over or landed for you? Or I might. Sort of, if they're more quiet and they need a bit more help, I might recap saying these are the things we covered and these are some of the things that I thought we could keep talking about and I just want to pause that there for a minute and see if there's been anything else that I missed or didn't get to talk about or if I've got any admin that I didn't cover, I'll say, look, I want to... I definitely want to get into some of that.

I just want to make sure I quickly cover this stuff first. So again, I really just talk about what that looks like and depending on the modality, I might do a bit of a meditation or a grounding reflective kind of exercise, but I would have told them that that's part of how we work.

But again, if someone's coming in a real flurry because they've missed the bus or something's happened, I might help ground them first before I go into any of the other stuff.

[00:13:46] Bronwyn: Yeah. You want to attune to them. I do something similar and I say, um, I really want to know about the in between, what, what happened between now and last session. Sometimes people don't think about the first session together, but sometimes they're like, oh, I forgot to tell her this or like, oh, I shouldn't have put it like that, that kind of thing. And I wondered if you had any thoughts like that?

I find that's really helpful because sometimes they'll be like, Oh yeah, I really wanted to tell you this or like, Oh my gosh, I was ruminating so hard after our session. I just felt like a really vulnerability, like, you know, hangover. And so that's a really good, um, starting point. Um, and sometimes they'll be like, I was overwhelmed for like a week after our session. And that's a really good insight for me, because that says to me, make sure you check in with this person about how overwhelming the information is and how overwhelming the session might be for them.

[00:14:35] Marie: Yeah, no, I, yeah, something similar.

[00:14:37] Bronwyn: And then, I check in with them, but then I also, um, I give them a bit of like how I do therapy. So I usually say to them something like the way I like to do sessions is that I bring an idea or two to come to sessions with. And like, I look at what you want to get out of therapy and I'll come with an idea to help us with that. And if you want to bring something to talk about at sessions, then we can absolutely go with that as well. So it's very much shared space. And if you don't like my ideas, then we can, you know, on the fly, come up with other ideas. Very flexible. Um, well, how do, how do you go about doing that?

[00:15:07] Marie: Yeah, something similar. I think it might take a few sessions to really understand the goals, like why, why now, uh, what's happened, and then sort of being able to distill that into how would we know this is working? What would be different? And then I come to that with either some ideas.

But again, whatever I tell them to, however we go into work, we talk about that. So I might say, you know, if it's more relational, we might say something like, you're coming to me cause I know that you feel really uncomfortable in social settings. And sometimes there might be a whole session that we just understand what that's like, but if something has happened in between, then we can work from that event as it's kind of fresh in your mind and trace that back to some of the things that you struggle with when it comes to social settings. So explaining that sometimes it might be digging into the past to find something we can shift there. And sometimes it's something that's really recent that might feel insignificant, but it activates that same issue for that person that we can explore. And couples therapy is very much like that too, where what they come in with is, "Okay, now I can hear that you struggle with, feeling appreciated". I now have a tool for that, that we can do.

So, you've got a bit of a, an idea as you conceptualise the case, and then you see, so if you work really relationally, then even the question of what resonated with you, that might even just be a whole session of, okay, what made it hard to ask me that then? How does it feel me asking you about that now? Even that becomes part of the work. So it's really, again, in once you're clear in your style, how do you explain that to someone?

[00:16:58] Bronwyn: Yeah, that's a really lovely way of putting it. And I really like how you put it with why it's, it could be important for couples even to bring up stuff that's happening in the present, because it may relate back to the goals that they have brought to therapy because sometimes clients don't understand the significance of say like they fought over who's taking the trash out and they might not understand that relates back to a key presenting thing that they've come to therapy with. So giving them a bit of rationale around why that might be important to notice and bring up sounds important.

[00:17:34] Marie: Yeah. And with some clients, especially when I'm looking at maybe more of my ADHD clients, they can, some of them can spend a whole session talking about something and then leave and think that's not what I wanted to talk about. So keeping that in mind, I'll allow maybe 10 minutes or so for that. And then I'll gently with permission, interrupt and say, is this the stuff you really wanted to talk about today? Do you need one of those venting sessions or do we want to pick up with XYZ?

So I would still bring them back into that because that's, I see that as part of my job. Otherwise they might feel completely dissatisfied that they've been going to therapy for six months and they're not getting anywhere. But part of the reason they don't get anywhere is because they get excited and they overshare, but then that's what they need some help with is how do I stay back on track and how do I, you know, I need someone to help guide me. If they knew how to do it, they probably would do it already.

So it's finding this balance of making the space useful and also using your knowledge and skills of can we just check in that is that an avoidant technique? Is it that your brain's just really excited and maybe that's not what we need to use this for or, you know, whatever. So actually trying to understand that can be really helpful.

[00:18:51] Bronwyn: Yep. Absolutely. This has triggered a memory in me because really some of my earliest feedback from clients when I was a provisional psych was, like, they would say to me, if I keep on talking, interrupt me, please tell me to stop. Um, and so they, and I had a few clients say that to me, I think precisely because of what you're describing, they would be excited or start talking about something, but it wasn't really what they wanted to talk about. And then they would be like at the 45 minute mark. Okay. I can talk about the thing now, but I've only got five minutes. Um, and then they would leave feeling quite dissatisfied.

So one of the key skills that I do, which is similar to yours is that, I might allow it to go for like 10 minutes and I'll be like, I noticed we're talking about this subject and I'm very happy to continue talking about it, but I just wanted to pick up that last time we're talking about that. And I wondered if you wanted to talk about that a bit more or even something else. And you know how frequently clients would be like, Oh yeah, this wasn't even the real thing. I wanted to talk about this. That happens so often.

[00:19:47] Marie: Yeah, absolutely.

[00:19:49] Bronwyn: So it's, it's a good skill. I like that one.

I reckon this might be a difference between us and I think it's due to with our training, but one of my first jobs as a provisional psych was in a six session service. So I'd get these clients and, they're usually quite complex, but it was a free service. So they would come to our service and we only had six sessions. And so, it was quite time pressured and I was trying to do the assessment in one session. You give the formulation and treatment plan in the second session and then you progress session three, four and five with the work and then you do a closure session at session six.

And I think it's like, I've eased up a bit that I'm like, okay, you don't have to get everything done in the first session. You don't have to give them the formulation complete in the second session. But I think I'm still a bit, bit hurried in that, and I just wanted to see if you're a bit different about, like, do you share the formulation with them in the second session or the third session or even later?

[00:20:47] Marie: Not in that same structured way because I don't work from that sort of medical model in that, in that way. I would still talk about the limitations of how they've found me. So if they've come through VOCAT, that might look different to TAC to NDIS. So it's still really understanding the referral pathway and then the frequency of sessions or the financial constraints and then actually being able to say, "So, you know, we, You've had your Medicare, you know, your mental health care plan that gives you 10 sessions. Just from what I've seen, I think you might need up to 40 to manage this. So, is that possible? And if not, then maybe we can't go there. And this is the piece that we focus on instead".

So, I don't do a lot of diagnostic tools. I, I, I'll DAS and a K10 and a couple other things, more for reporting for the GP. But to have some baseline data. Because I find things are constantly evolving, and as I'm doing work, maybe I'm doing EMDR, then I might think oh, I really want to kind of know a bit more about these schemas, so I might switch to using some of that, and as we're doing those schemas, then it's like oh, that, that parts works really good to bring back into EMDR, so I don't have it as structured, I might just bring it up in a more informal way, saying this is what you've said you want to work on, and I would talk about any, like, there's no point sending all this intake paperwork, asking for all these questions and then ignoring all of that. How rude to ask someone in an intake session about all these questions and then ask them the same thing, like, have, I would be like, what, didn't you friggin read it? It took me all day to complete.

So, I would say, based on everything I've collected, it's indicating that these things might be a bit of a concern for you. This is what I'm noticing or this is, you know, I want to learn a bit more. So I always talk about what I'm doing and why.

[00:22:42] Bronwyn: that's really important. It's like, I feel like for you, you're, you're so much more chill, which is lovely. And I think I need to take a bit of a chill pill with the session two. And I'll tell you what shows up for me, which I reckon will show up for some other early career psychs, I worry if I don't give them enough value in the first few sessions then they will leave.

It sounds like I have a big abandonment schema, but I actually don't. But I, I, maybe it's because I wonder if they will wonder whether I'm competent. That's, that's, that's more like me. That's the underlenting standards. Yeah. What do you think of that?

[00:23:13] Marie: I think that's really common and I can totally understand that. And I think that's magnified in private practice where we see the money exchange. What I've learned to, to do and take a step back is that if that's overwhelming and we flood the person, they're going to learn nothing. So if we're over, over educating, we're actually not allowing then for that experience, to tap into the emotions, to process things, so we need to take into account what we know about how the brain works, how information is absorbed. If they're wanting to hurry a lot, then that's still information of, okay, what's this about for you?

I know if I was learning something new, like imagine if you were trying to learn Japanese and in that first tutoring session the tutor gave you the three different alphabets and like a song to learn and then gave you a movie to watch with subtitles and they wanted to jam pack your Japanese experience with all of these things, you're gonna leave thinking I don't know where to start and I already feel stupid.

[00:24:17] Bronwyn: It's too much, I've literally done online courses that have been like amazing, I've loved the presenter. Um, so there's self paced online courses, but then they had like 20 resources for each module. I cannot, I cannot read all of these. I just thought this is overwhelming. It's kind of, uh, yeah, making me feel stupid, but also it's like, uh, reducing my capacity to learn in a way because I'm like, Oh God, I can't do all of this.

[00:24:41] Marie: Yeah. And so when, for someone, I've done a bit of work in trying to understand adult learning and course creation, having developed a myself, and really distilling it and simplifying it, and what I want people to do is to complete it and action it. If they feel so overwhelmed that they don't look at it, my goal is not to just sell it.

I actually believe in the product, so I want them to get the benefit from it. So if I'm overwhelming someone in therapy, to the point where they feel like a failure, or they, uh, haven't done their homework, so they don't want to come back. I'm doing them a disservice, so they're not actually getting the treatment.

[00:25:20] Bronwyn: I think you're right. And I'm on board with this. I am like, okay, yep. I need to slow down. I'm overwhelming them too much in that session two. But here's another worry. I'm worried about the, I'm worried about the family and the partners. I think, I do think behind every person who comes to therapy is someone else who is hoping that this will work for them and that this will be a good experience, um, in, in those people who, who do have people who love them.

And so I think about, okay, well, this client's going to potentially, if they've told their partner, they're going to therapy, they'll be like, how did therapy go? What are you doing? And I don't want the client to be like, Oh, you know, we just talked like, well, I didn't really feel like I got much out of it.

Yeah, I worry about that, but you know, hearing myself talk about this, I'm like, don't worry about it. You shouldn't be worrying about that!

[00:26:06] Marie: No, they're really valid worries, because... someone brought up in the supervision group, uh, this week, which I love the analogy, like, do you stay awake? And if someone's listening, and you do stay awake thinking about this, I apologize. It's going to be a flawed analogy, but do you stay awake at night thinking about who is winning the Tour de France?

[00:26:26] Bronwyn: No, I don't. Um, one, I'm not a big, like, Tour de France fan, but two, like, you know, they're doing them like, I'll find out later.

[00:26:39] Marie: Yeah, or you don't care because you don't particularly like it.

[00:26:42] Bronwyn: Yeah. I don't, I don't really care.

[00:26:43] Marie: Yeah, so the fact that you're worried about some of this stuff with your clients, it's because you care. You care about their life, you care about what they're doing, you care about their relationships. So it's something to tune into and be like, I'm worried about it because I care. I'm not worried about who's winning the Tour de France because I don't care about cycling. So it's already, it's signaling to you a bit of a value, and I think okay.

If you looked at some of the sort of feedback informed treatment, whether you look at Scott Miller's work or session rating scales, then bringing that into your session can actually help you figure out where this is. So it might be saying to the client, last session, I feel like I bombarded you with stuff. I wanted to check in. Did that feel like a lot? And if they said, yes, let's try and slow it down. And if you had a really slow session, you might say, I really... this was a different pace to what we've had in the past. What was that like for you?

And so maybe you end things five to ten minutes earlier to do that recap. And then if they're like, well, yeah, I don't know what we covered today, then you might be able to bring in that education. Well, what I was hoping we would do, and we've just done it through osmosis, is I wanted to slow it down, give you a space to really tolerate some of those difficult emotions, to feel them in your body, and I know that that's new for you.

So you might get to tell them what it is that you have shown them to do by slowing things down, and then you can rehearse. If your partner, parent, you know, you hop in the car and your parent asks you, what did you do in therapy today? What do you normally say? So you can actually script some of that and role play it and help them kind of figure it out.

[00:28:21] Bronwyn: There's a few things in that that I wanted to point out. One of them is that with, um, Scott Miller's work on feedback informed treatment, one of the things that I've read in that is that if you want to get feedback from clients, be specific. So don't be like, how was today's session for you? They'll be like, I don't know, good. But I really like how you said, like, this has been a session where you've sat with emotions more than usual. How was that for you? Or like, this has been pace. What was that like? So that's a really effective way to from clients. And I just wanted to point that out.

[00:28:55] Marie: Yeah, and I think it's because, like we chatted off air, I've been doing this for a lot longer that I have forgotten how to pin that down of, I'm used to doing it now, but I did start off with the sheet with the Likert scale and I would give it to people. And I think that we can evolve over time. And now I know I use a bit more intuition, which isn't just winging it. It's intuition built from, you know, over a decade of doing this, and lots of professional development where I can pinpoint, did you feel heard or understood, or, you know, if I know they have particular schemers or particular presenting concerns, I might say, what was that like when I was a little more assertive in our session? Or I noticed that you sent me an email in between sessions, which you haven't done before, what was that about?

So it's really being curious and reflective. The only way to know for sure is to ask them. And keep mind some want to be a good client. They want to please you. It won't be a perfect measure, but it's a really great place to start. It's better than assuming.

[00:30:00] Bronwyn: Yeah. I really appreciate when clients tell me that they want to be a good student, be a good client. And I'm like, thank you so much for sharing with me. Cause I do think it takes a lot of courage and vulnerability. It's like, I want to be good for you. And I'm like, no, but thank you. Thank you for sharing that. What would it be if you didn't, if you didn't try and be a good me you were more yourself? How would that be for you? Ooh, feels really scary. It's a great topic of conversation.

[00:30:21] Marie: Yeah, and that's maybe where the work is, right?

[00:30:24] Bronwyn: Yeah, absolutely. So Marie, I just wanted to hear about how you get into a session three and then I'll ask you about any other top tips for structuring sessions one to three.

[00:30:36] Marie: Oh Yeah, so I would, um, I go through my checklist and I have this all on, on demand training. It's very general, but I do have a bit of a checklist and I make sure I kind of go through it all. I'll use that third session to just check any of it and then do a bit of a recap of the, maybe the session frequency. So I try to book the first three a week apart and I kind of consider that in my head a bit of an informal assessment phase. And then I might sort of share that with the client and say this is sort of what I've noticed. Here's sort of my version of a case conceptualization. Now, moving forward, how do we kind of progress and avert some of those bits and pieces?

Any communications that I need to make with, you know, doctor, like really just making sure they understand those reporting requirements and still continuing to get to know them. Talk about, do you feel like you want some things to try at home? Do you want to experiment with like, do you want me to give you homework? Do you like to journal? So I also want to try and ask them about their learning style and what they want to do, because that's how I work. And even though I know some people who do more psychodynamic work, don't ask that as a client, that's really frustrated me because if I don't know that that's how they work and they never tell me that that's how they work, I'm going to feel like I'm always coming short. Or not maximising a session. So it feels like I'm just a boat floating in a big ocean. And I'm like, well, I don't like this.

So I'd still really clarify that. Talk about any... I always ask about if they've had therapy before what worked and what didn't, and the what didn't, I really focus on and check in. Like, what happens if I run the risk of doing that? So if I say something that's uncomfortable, when is it, something we can talk about? And when is it so, like, that's just a no go zone? How do we know that, how do we do that different with us? How will I know that if you're, if you've cancelled an appointment, is that you avoiding me? So I really talk about the process of therapy after we've had a few sessions.

With um, with the data you shared, I, I probably focus on that a little bit more with, with male clients in particular, because about 50 percent don't come back for their second session. And we know. We know, we know already that it's harder to get men into therapy disproportionately the workforce is female. So I would overt some of that and be really clear at the start that you're not, you're in the norm. If you think after the first session, I don't understand the point of this. Bear with me. We need to find a bit of a groove because it does take some time.

So using, yeah, using demographic information is helpful if it can, um, you can overt that stuff, right? So if you're working with someone in the queer community, we know there's higher risk of suicide attempts and self harm. We know that there's an overlap with body dysmorphia, eating disorders and maybe autism. So this information is only as useful as it helps inform treatment not to discriminate. It's to inform how we work or what we are maybe more attuned to and what we're going to look for. And it should be the same for medical services, but I can't talk to that.

But I would overt some of those things a little bit more saying, Session three, you've done more than 50 percent of men who attend therapy. What's that like? What's work? How can we tweak it? What do we need to adjust? Time, duration? Do we do it walking? Do we do it telehealth? Do we make it, um, less frequent, longer set? Like... and then we start to kind of adapt because all of those things are options. Half hour are an option. Walking sessions are an option. 90 minute sessions are an option. Like there's so many different ways of working. We don't have to be so rigid.

[00:34:27] Bronwyn: Yeah. I love how you talk about that so overtly. Like, it sounds like a real strength of yours and it feels like I'm like kind of coming into some of that stuff, like when you were talking about how you ask clients how they went with previous therapists and how would we know if they're approaching that? I think that's awesome because sometimes we will ask clients like, how has previous therapy? And then in our minds we're like, okay, I won't do that. But it's so helpful to ask the client, like what would be the signs that this is happening?

[00:34:57] Marie: Because that's a pattern for them. And be, if it's happened multiple times, it could be a pattern that is an underlying concern or a symptom of what they've brought to you, or just really either related or slightly tangential that we can bring in if needed. It's, it's part of the information.

[00:35:15] Bronwyn: Yeah. No, absolutely. Okay. Marie, I just wanted to ask you, is there anything, any other hints and tips and tricks that you have for early career psychs that we haven't mentioned? And then I will say, I've got two.

[00:35:27] Marie: So I would get you to think about write a checklist so, you can, you can attend my training and you get a checklist with that, but really thinking about what are all the bits that I need to know and cover and maybe start off with printing it out as a and just having it on your iPad or on your note, you know, your pad, whatever you use and get used to going through it and that can be, you know, if it's an NDIS referral, that might be different to Medicare too, if you're working in an organization. So being clear of session frequency, funding restrictions, um, gap payment, like be, Understand the admin side because it can be a really big rupture for a client if they feel like they've been ripped off or things ended after three sessions and they didn't realize they just got into trauma work, like being really clear about the parameters and having a way to understand and explain that.

[00:36:26] Bronwyn: Can I just add to that, because it's actually a huge gripe for me when, um, there's not clear admin processes for clients. I don't think it's understanding of the presentations that we see. So like clients often in distress, they might have limited like cognitive capacity and they've got, you know, a lot of distress in their lives. And I feel like, as a service provider, the least that I can do is make this an easy process for them and understand their funding and what's happening for them, so that I can make sure that this service goes smoothly for them. And so, yes, I would really recommend that, that people do that. It, it really provides a sense of relief for my clients to know that I've got this under control.

[00:37:03] Marie: Yeah, and I'm less, I'm less forgiving of people in private practice who don't do that, because I think you're now a business and that's your job. Just like you go to a restaurant, you don't care if it's a big one or a little one, you expect certain standards. So if you're going to be going out into private practice, I know you love therapy, but you are a small business and a service provider who also could do damage to an entire field.

So you need to get your systems and processes up to scratch. You need to have a way to have a consent form, be clear on the funding requirements. Don't be flappable, you know, flappable and distressed in sessions. You need to be clear, contained. There's no one else to blame but you. So you have to put in the supervision. You've got to charge for longer sessions. If you need more admin time, you need to book in more breaks like this. It stops with you, unfortunately.

[00:37:58] Bronwyn: Yeah, it's a huge responsibility but it's so important to fulfil those responsibilities.

[00:38:03] Marie: Like, I've been a client of so many people and I've had some who have no consent form, have ones that they've clearly copied from another practice that had their information on it. I had one online form. Someone must have used it. They, they sent the link wrong and so when I filled it out it had someone else's Medicare card details as part of the question. I've, I've just had all sorts of terrible things and I'm like I'm sorry but that's just not good enough. If you, you don't like that stuff and you can't do it, go work for someone else. I really don't think it's okay.

[00:38:38] Bronwyn: No, it's not. And yeah, it makes me feel upset, you know, like getting mental health help for my family members. Um, and my family members are DVA, um, because my dad's, uh, been in the Navy. And so my family members can access, counseling for free. And the amount of times that I've helped to set them up with psychologists who won't inform them of that and will make them use a mental health care plan for like 10 sessions. And I'm like, this is supposed to be free. Like they need to make sure that they contact DVA. You don't even have to sign up to DVA to cover this. Like, come on people.

[00:39:10] Marie: Yeah.

absolutely. So that's, that's one of the first things that I get people to think about is good rapport and enhancing clinical outcomes starts from before the client's in the room. It starts from grounding yourself, understanding the systems of processes, and with time, like, now, if I get a Medicare referral, I don't need to go back and I know the spiel. I know the restrictions. I know the item off by heart. Like, that's fine. But I didn't start like that. And with my regular clients, the less new clients I have, I might be able to back to back a couple because I kind of know their story already and they've, their story is so fresh in my mind, whereas new clients might require more time.

So it's really taking the time to do that properly. And you can't, then even maybe overt it at saying, look, this is, this is an EAP service. We've only got three sessions together. There's all this stuff I'd love to do, but that doesn't feel like it's going to be useful for you right now. So I'm just going to cut to the chase. This is how I can help you in this short amount of time. How does that sound? Like you might have to use a bit of humor being like, yeah, this feels like a rotisserie of just lots of different people. And you come, it's really sterile. That's okay. While that's the restriction, how can I make it helpful for you?

So whatever, it is, you can overt that and just make that clear that these are the limitations of this.

[00:40:34] Bronwyn: No, totally. And is there anything else?

[00:40:36] Marie: I'd be being clear about boundaries and don't expect the client to follow them. It's you that has to follow them. So if you've said, I won't reply to emails midweek because I only work Mondays. So if you email me Wednesday, I won't be back until next Monday. And they email you, it's on you to not reply.

[00:40:54] Bronwyn: It's so true. I've, I've had supervision around this. I'll tell you what I've had, cause I've been like, I should, I don't, I don't reply to clients. And then, um, I replied to a client and my supervisor was like, why did you reply to them? And I'm like, cause they asked me a question and I was, I was like, I felt compelled to reply to the question. And he's like, no, you don't. And I'm like, oh, okay.

[00:41:14] Marie: Or have, um, an auto office reply that just says...

[00:41:18] Bronwyn: Yep.

[00:41:19] Marie: ...you for contacting Marie. I currently only work one day a week. If it's regarding a cancellation, you can do it through the, I don't know, Halaxy portal. You can contact admin. If it's an emergency, contact this. I won't be checking my email in between my work days.

So, figuring out some of those process things, again this, this is where it's maybe a pet peeve of mine around the different modalities. It's got nothing to do with what, whether you're a psychologist, OT, psychiatrist, like some of this stuff, it doesn't matter. This is the basic customer service bit. Funny enough, I think this is the most important and it's what's never talked about or explicitly or trained, like no one gets trained this

[00:42:05] Bronwyn: No, they don't. Absolutely. It's usually something that we have to find out through mistakes, but you know, it shouldn't be that I've had to learn through mistakes. We, we should have clear guidance around this.

[00:42:15] Marie: Yeah, and when I listen to, I don't know if, I mean you are a fan, we've talked about it before, the Very Bad Therapy podcast... so many of those ruptures come back to not communicating clearly.

[00:42:27] Bronwyn: Mm. 100%.

[00:42:28] Marie: You work, how you can work, sessions in between, boundaries, uh, communication with partners, with parents, with children. Like, all, a lot of that comes down to that not being clearly articulated or understood.

But then we also can't take full responsibility for everything, right? Because we're human make mistakes and we overlook something and sometimes clients need to take some personal responsibility. We had one parent who, after two sessions, three sessions, was like, I feel really lied to. I called and asked for a psychologist and I had a mental health social worker and I was like, it's on the website. The email, the confirmation email in your introduction. You still had three more sessions. What is really about?

So at some point. We can't address everything of everybody's, and we just have to accept that we will get it wrong sometimes, and that's okay.

[00:43:26] Bronwyn: Nope. That's fair. Okay. Is it alright if I share my two things.

[00:43:29] Marie: Yeah.

[00:43:30] Bronwyn: The first one is I'm very interested in clients strengths. This is something I tell my clients explicitly, um, usually about three quarters of the way through the first session. And I'm like, I've heard a lot about, um, your concerns and it's good that we've been able to understand them a bit. I don't generally like seeing people as a bag of problems. So I usually also like to hear about the good things about them and I'm wondering if you could please tell me a bit about your strengths or things that you're passionate about, you know, what gives you a bit of joy?

And I find that this is really helpful for two ways to it. The first way is that it helps me work out, um, how they see themselves. Um, and sometimes they struggle with it straight away and they're like, I cannot think of a thing. And then I say, what would someone who loves you say the strength about you? usually better able to give them that. But if they can't think of anything, then that immediately says to me, okay, like we've got somebody who, who cannot like think of anything good about themselves, but they can tell me all their problems.

And then I usually like to say to them, like, it's really important for me to know about your strengths because this isn't your first rodeo or first difficulty that you've had here. You've come through difficulties in the past and I want to use those strengths to help us in the present.

[00:44:36] Marie: Yeah, I love that. That's really great, Yeah, I'm gonna add that to mine.

[00:44:40] Bronwyn: Thank you. Yeah. No, um, I think as psychologists, like particularly, like we're just trying to like Yeah, pathologize. And so I'm like, I, I wonder like if clients have that expectation, they're like, she's going to be here to make me feel bad about myself and how like crazy I am. And I like to reassure them that they do have good things, positives about them.

The second thing I do is I usually tell clients about the change process. This usually how much I told them usually varies depending on how much expectation I think they might have for like, maybe they're not very, uh, realistic about what change looks like. So I usually say something along the lines of like, you know, it can be hard to take the first step in, in change and getting to where you want to be. If you already knew how to get there and the path and how difficult you'd already be there and you wouldn't be here. So there's gotta be a good reason for you to take the first step and that usually ties into values, but then I'm also like, you know, change requires you to usually go outside your comfort zone. So this will be a difficult process, but I'm here to help you along the way. And I'll make sure that we've got the tools to help you get across.

[00:45:42] Marie: Yeah, well, which, the way you phrase it, actually, if you look at the, um, taxonomy of deliberate practice, that's instilling a message of hope. So if you look at those core bits of deliberate practice, that's, it's giving a message of hope.

[00:45:58] Bronwyn: Yeah. And I try and do that. I try to, because I think a lot of clients when they come to us, like, you know, they've been struggling in this for some time. And sometimes like, you know, going to therapy is like, you know, I've tried everything. This is the last resort. And they might feel like there is no hope. So to have somebody say to them, look, there is some light at the end of the tunnel here, and I'll help guide you along the way. I know it seems dark and scary, but I'll be here with you. I think does provide people with, yeah, a lot of hope and good feels.

[00:46:22] Marie: Yeah, one of the practitioners in my peer supervision group was sharing some resources from a... I guess, a conference that they went to and they said this one particular presenter, her philosophy is Everybody is already whole and capable. And so even, you know, if you've got philosophies like that, that's worth sort of sharing and saying, I see you as, you're not broken. You might have some coping strategies that don't serve you well, but I see you as worthy, as competent, as whole already.

So there's different ways, different spiels you can have based on what modalities you use or your own style or if you're fusing that in with any spiritual or religious, um, beliefs. Like, you can bring some of those things in.

[00:47:13] Bronwyn: Mm. One hundred percent. Yeah. And like, I guess like, did you build up your kind of philosophy of people over time? Like, do you reckon 10 years in you're like, you know, I've got a pretty solid idea about my beliefs.

[00:47:26] Marie: Oh yeah, and they, they changed and there was so much originally, um, it was interesting because I was actually just reflecting on it after a recent podcast episode that I had released called, um, Growing Yourself Up. Initially, I was very good at sort of pinpointing what someone else was doing wrong, maybe pathologizing that, coming up with a diagnosis and saying, well, of course, that's their dismissive attachment style or they're going to be irritable because, you know, that's a symptom of depression. And it did change over time to start to recognize the role that I played in that, even within therapy.

So personally, it's been, you know, incredibly useful to start reflecting on that. But in therapy, starting to attune more to. What I do in the space can, can really impact how well this goes. I can really get someone on side or off side. I can, sometimes I can do the best thing and it might not be what that person needs, so I don't have to take full responsibility, but I do play a role in that. And really starting to use that as a tool to guide the therapy in itself can be really, has been a real big change I think for me.

[00:48:36] Bronwyn: No, awesome. Okay, there's just one other thing I wanted to mention, and I reckon you'll be better at this because of your social work training than me, and it is a mistake that people can make is ignoring culture or contextual factors.

I had this happen to me like really early on when I was, you know, just starting out, and I remember someone came to me with a workplace bullying issue. And I think just because I was starting out, I was using a very strict CBT approach. So thoughts, feelings, behavior, and I completely missed that their workplace was full of misogyny, and it was a very much a boys club. So they were experiencing this workplace bullying that was a direct result of these attitudes that were, I guess, like discriminating against my client.

Um, and so the client graciously told me that they felt very unheard in that. And it really highlighted to me that we need to consider these factors and like, I'm just going to assume that you do this much better.

[00:49:41] Marie: I'm getting better at it, and I find that it's then helped create more of a reputation for working with a certain presentation. Again, I think the more you, um, niche down, you get familiar with the particular population's difficulties or challenges. So, if you worked at somewhere like Foundation House, you're going to be a lot more attuned to the impact of trauma and the refugee and migrant story of people who come from countries that are experiencing a lot of conflict. So that's going to be something different to working with... in the queer community. If you're working in, with a lot of people with disabilities or disabled people, then you need to start to have a language around internalised ableism, discrimination.

So I'm getting better at overting that. Sometimes it's more, professional than other times. And sometimes I have to sort of say, you know, you know, a person, you know, who's a big, tall man, I might say, I don't think you can express anger in the same way because given your stature, it's probably not safe. And it's safer than you were black man, but it's still not safe. If you get angry, people get scared.

So me being able name that for them can be really helpful. If I'm talking with someone who is from a migrant family community that we know experiences discrimination, I might check in with that. Like during COVID, I did check in a lot with my Asian Australian clients and saying, has this changed for you? Some will say yes, no. Maybe, I don't know, is it something we need to bring in? And I can then be honest, more honest with it. Look, there'll be things that I can't relate to from a lived experience because I'm not from that background. I just wanted to name that I can see that that might be a factor in this.

So, I think we do have to be aware of that intersectionality and talk about it because It's so, it's important for the work, but it also can be part of the story that's led the person to be there. And a great source of strength and resilience and an amazing resource.

[00:51:54] Bronwyn: Yeah, it's like, I'm getting really good at talking about neurodivergent sources of trauma just from being a neurodivergent person in neurotypical world, like ableism, medical gaslighting, um, feeling unheard, having to mask, that kind of stuff, which can, you know, cause like a lot of damage and harm to our neurodivergent folk. Um, but yeah, I hear what you're saying. It's like, recognizing this can be really important.

Hmm. Okay. Um, I could talk about this forever, I reckon. Um, but you know, we've got things to do. I'm sure listeners got things to do. What's the biggest takeaway you hope listeners will learn from our conversation today?

[00:52:32] Marie: Talk about the talking.

[00:52:34] Bronwyn: Hmm.

Wise.

[00:52:36] Marie: I can't take for that. That was my, um, my lovely supervisors at the Boovree Centre. But it's, yeah, it's really just, it's talk about the talking and overt the process.

[00:52:47] Bronwyn: So helpful. And do you have any favorite resources you can plug for early career folk?

[00:52:53] Marie: Yeah, so I do have an on demand training called Enhancing Clinical Outcomes in the initial three sessions, so that's on my website. That's about, I think, 60 to 90 minutes. I would Google the Taxonomy of Deliberate Practice, and I think that gives you a really good tool, because it's not about, you know, Diagnosis, it's not about treatment modalities, it's around the bits that you bring to the room, and it gets you, it gives you prompts to actually script, if you're looking at introduction, how do you say it, how do you greet someone, how do you bring them from the waiting room. So if you look at some of Scott Miller's work, and I think there's a few YouTube videos that he talks about that. that resource, then picking only one or two to focus on. Cause again, we're human. So we can't focus on improving all of those things. So we then need to be deliberate about the bits that we work on and how do we measure the growth of that?

So it's probably really overwhelming to people who've like, I have just spent all these years and I've got this massive HECS debt for all these skills. And you're telling me that the most important thing is the relationship. And they've not taught me that. Oh my goodness. Yeah, unfortunately that's, that's the case.

[00:54:01] Bronwyn: Yeah. Unfortunately. Yeah. That's it. And I will say that like, yeah, focusing on that, I think returns... has so much return. So like, um, I was saying this to Marie off air, but I reckon like, client retention is, is probably a strength for me. And I literally used to like write out scripts. I used to practice scripts. I used to think about and reflect on what I could do differently, like what happened in sessions. And I would say like over the past few years, I've probably had one or two clients not come back after our first session. And like, I can easily pinpoint why. So yeah, I'd highly recommend it. Sounds like a great course, Marie.

[00:54:37] Marie: Thanks. And even this, hopefully it's given people something to think about, so this conversation in, in itself will be, I guess, an eye opener for some folk.

[00:54:45] Bronwyn: Well, thank you so much, Marie, for coming on. It's been, it's been eye opening listening to you and I've certainly learned lots myself. I need to take a chill pill at session two, that's my main takeaway.

[00:54:55] Marie: And I'm gonna ask more about strength. I love that question.

[00:54:59] Bronwyn: It's so good. I love hearing about their strengths as well. It's really good.

So, As always, listeners, thank you so much for listening. If you're loving the show and you don't want to miss an episode, do press follow on your podcast listening app. You can do that in Spotify. You can do that in Apple. You can do that in probably every other podcasting app. If you do that, then you get the episode straight away. So then you don't have to keep on, you know, coming back and finding it. It's really good.

That's a wrap. Thanks for listening, take care of listeners. Catch you next time. Bye.