**Author's Note: Other than public figures or people identified in the media, all other persons in this book are either composites of individuals the author has worked with and/or have been given different names and had their personal identifying information altered to protect and respect their confidentiality.
INTRODUCTION: THERAPY INTERRUPTUS
"Hello, my name is Marjorie. I’m looking for family therapy for my husband Arnold and me and our two teenage boys. We have some communication problems." Per the advice of many veteran therapists and therapy trainers, the therapist sticks to the practicalities and logistics: setting the fee, going over any insurance or third-party-payer requirements, of scheduling up the first appointment, and getting names and phone numbers. Marjorie, Arnold, and teens are set for 4 pm next Thursday. The therapist confirms that they have the address, reminds them to bring their insurance subscriber card, and also to arrive a few minutes early to fill out the General Information and Consent form that will be on a clipboard in the waiting room.
Later the same day, the phone rings again. “Hello, I'm interested in seeing someone for therapy. My name is Balfour and I was referred to you by someone who knows someone... who used to see you. I have some issues I want to work through and would like someone to help me process them." Once again following intake protocol recommended, the therapist went over logistics and scheduling. An appointment for the following Thursday at 5pm in the afternoon is set.
"Awesome," thinks the therapist, "two new clients that fit right into the opening in the schedule Thursday afternoons. I'm rocking!" At 3:50 pm the following Thursday, the therapist walks through the waiting room for a rest room break and notices that no one is waiting. There should be someone there… two adults and two teens there by now. At 4 pm, no one has shown up. "Hmmm, maybe a bit of traffic or trouble finding parking? No big deal… I hope." 4:05 pm, 4:10 pm, 4:15 pm… oh oh. At 4:20 pm, the therapist calls Marjorie’s phone numbers: first, her cell phone and then, the work number. No one answers, and the message function turns on. The therapist leaves the message, "Hi Marjorie, this is _________. I was expecting you and Arnold and your kids at 4:00 pm today. Give me a call to let me know what you'd like to do. We can reschedule for tomorrow or next week. I'll call your other number as well." The therapist calls the other number and gets the message function again, and leaves a similar message. Marjorie… and Arnold never return the call. Bummer! Well, there is the other second new (can't be the "second" when there wasn't the "first!")... that is the only new client Balfour at 5pm. The therapist reads a few e-mails, finds some paper work to do, and peruses the Internet for the latest news. Some interesting circumstances in the political economic world in an online news article catches and holds the therapist's attention. Suddenly, the realization that is it 5 past the hour... 5 minutes past 5pm when the new client was supposed to show up. "Damn! You’re kidding me!?" and other non-clinical thoughts and feelings explode in the therapist's consciousness if not out loud. Why not out loud? It's not like there are any damn clients around to hear the humanity of the therapist! The bane of therapy- especially, private practice therapy has occurred. It's a no show. It's two no-shows! Each one is an unconsummated appointment, a tease and disappointment, and a waste of scheduled time. The no show strikes at the existential therapist sense of self. It just sucks! What could be worse? Well…
Blair and Thompson call to set up therapy... and they show up! They came for their first session after contacting the therapist based on finding the therapist on a referral list. The initial phone contact played out pretty much as it had with the phone call with Marjorie or Balfour. Blair and Thompson dutifully showed up about ten minutes before their appointment, found the clipboard, and filled out the General Information and Consent form. They were going to be a strictly private pay client, so there were no insurance cards or forms to deal with (hallelujah!). The first few minutes of the session confirm that there were no logistical issues. Blair took the lead and said that they had some communication problems and felt that therapy would be beneficial for them. She gave the background of their relationship (met in their mid-twenties, together eight years, and married for two years). She described how sometimes they would get frustrated about trivial things, and then Thompson would "kinda shut down for a while." Blair said she could tell that Thompson was upset and it saddened her to see him unhappy. The therapist explored what that meant for Thompson. Thompson admitted having a hard time with confrontation and especially, with any conflict. He had been drawn to Blair's exuberant outgoing energy. It made it easier for him since he was kind of shy. However, with prompting from the therapist Thompson revealed that sometimes he felt overwhelmed with Blair's enthusiasm and confidence. She was a rapid processor and highly articulate verbally. Sometimes, he could not get his thoughts out quickly enough and he would just give up trying to express his feelings, perspectives, and needs. Thompson was visibly excited to be able to reveal his experience in the relationship. He affirmed to the therapist that he enjoyed therapy so far, and was optimistic that it would be useful. Blair agreed that the first session had been promising. She said she was glad that Thompson could get these thoughts and feeling off his chest. The therapist set the next session for the same time the following week. The therapist thought the session had gone well, there was good initial rapport established, and was looking forward to the next session and working with the couple. The next day, the therapist found a message on the answering machine from Thompson. Thompson gave his regrets, but they were canceling their appointment for the next week. They had decided to "go in another direction." What!? What the heck? What had happened?
Justine had said virtually the same things that Balfour said in the initial phone call. Unlike Balfour, Justine came to the scheduled appointment and to the next one as well. When the therapist asked what issues Justine wanted to work on, Justine said she was trying to figure out what to do with her life. She was in her mid-twenties and a couple of years into her first job at a small law firm after graduating from college with a degree in Communications. Her fiancée had just joined investment banking corporation as a junior attorney. Life was progressing as they had planned from when they first got together as college students a few years ago. Their families liked their respective children's fiancée and were looking forward to the wedding, pregnancy, and grandchildren milestones. The therapist mostly listened to Justine the first session and most of the second session. As with many therapists, the therapist used the initial sessions for getting background- an intake process of gather information for assessment and then establishing treatment goals. The therapist let Justine set her own pace and tried to allow her to present herself and her story without a lot of questions. Holding back feedback so not to presume the direction and goals of therapy felt appropriate to the therapist. There were no "ah hah!" moments, but the therapist felt Justine to be cooperative and invested. They set the next appointment for the following week at the same time and day of the week. Justine never showed up, never called, and never returned the therapist message to reschedule and find out what had possibly happened. What!? Again!? Therapy interruptus just when the therapist felt they were getting started. Therapy foreplay without consummation!
Putting ones shingle out for practice whether in private practice or as an agency does not guarantee clients will seek out ones available services. Marketing oneself, ones services (skills, experiences, expertise, and availability), or the agency's parallel the principles for increasing the probability of a successful phone intake, where the client will subsequently schedule an appointment that results in the client actually showing up. The same principles apply for increasing the probability of client involvement in a first session becoming an invested client (individual, couple, or family). Of utmost importance, these principles and processes also parallel rather than are counter to sound clinical practice that maintain integrity. As the therapist experienced with Marjorie and Arnold or Balfour, an appointment is not a first session. As the therapist experienced with Blair and Thompson or Justine, a first session or even a second session is also not a committed and invested client. The first contact and the first session of therapy can portend successful work or create problems that unnecessarily complicate, slow, or doom therapy to failure. "The initial stage of intervention, termed the introduction phase, includes some crucial aspects of the therapeutic process. First sessions are focused around the goal and task segments of the therapeutic relationship… the therapist should focus on maximizing the family's initial expectation of positive change by setting realistic and useful goals. During this stage the therapist attempts not only to become familiar with the parameters of the family and their potential for change, but also to elicit and structure information and develop a plan. During this phase, the therapist collects information and the manner in which he or she elicits and receives such information may be essential to the development of trust and a positive rapport with the clients" (Thomas et al, page 21).
Another way to conceptualize these initial phases is that therapy or clinical practice commences immediately with the very first contact and proceeds through the initial phone intake and the first session. The very first contact is in how the therapist or agency presents oneself or itself to the general community in various forms of outreach, marketing, and self-exposure. Thus, marketing has critical therapeutic components that therapists or agencies may miss. The practical and conceptual guidance in this book focus specifically in the first contact by phone and the first session, while giving comparable principles for marketing to the community.
SEVEN KEYS TO CLIENT INVESTMENT
The seven keys to create investment in therapy or the Seven C's of Therapy propose a framework to approaching the client: individual, couple, family, or group during the initial contact and the beginning of therapy for the therapist. Many of the principles and ideas are appropriate all therapeutic populations and circumstances, while some may be respectively best suited for individual therapy, couple, or family therapy. Some principles may be specific to a type of therapy and problematic for other types. The Seven C's of Therapy presents three key goals for the therapist:
three initial assessment goals:
and one ultimate goal of
that the client and the therapist hold together. These goals are important throughout the entire process of therapy but are especially vital in the beginning of therapy. Although relevant to all client compositions, the goals may have particular challenges and nuances for couple and family therapy. Failure to address or achieve the first three therapist goals may preclude the essential therapeutic context from being established and/or for therapy to terminate prematurely. Or, therapy may not to be initiated from the first contact on the telephone between the therapist and the prospective client. The three goals for the therapist in the beginning of therapy are developmentally related, and set a sound therapeutic foundation to facilitate the final four goals for the client, couple, or family that are the essence of the therapist-client relationship. The three goals for the therapist: connection, credibility, and control are presented conceptually separated but are actually interconnected and cross-referenced. The first three assessment goals for the individual, couple, or family: communication, container, and capacity are also presented separately but are interconnected. The therapist should begin addressing these assessment goals in the first contact, the first session, and continually re-assess them throughout therapy. The last or fourth and ultimate goal of clarity if achieved will signify the successful end of therapy whether the individual progresses, the couple stays together or not, or the family stays dysfunctional or becomes functional.