I firmly believe the initial session with a client is the most important moment in the therapeutic process. This is the moment a relationship begins. It’s also often the moment a relationship ends. The most common number of sessions a client attends is one. This initial session is the space where your clients choose to begin a process of change in earnest, or decide that it’s not worth the effort. The importance of this session demands that everything be done to allow success for you and your clients. The ACT matrix has changed how I do therapy forever, and it all begins during this initial contact.
Setting yourself up for success means finding a rhythm that works for you in your intake sessions, understanding where clients are coming from, and creating an environment that is welcoming and hopeful. This chapter will cover the methods that I have found to be most effective for setting up the kind of work I do. Again, and again, the ACT matrix has served to foster these crucial elements. After reading this chapter you will be able to implement these methods for yourself in entirety, or pick and choose which will work best for you. Either way I encourage you to experiment and be flexible with your thinking.
For more great information on the importance of the initial session, and the value of doing brief work I highly recommend Brief Interventions for Radical Change by Strosahl, Robinson, and Gustavsson. https://www.newharbinger.com/brief-interventions-radical-change
When clients present to therapy for the first time we need to keep in mind where they are coming from in terms of their experiences of therapy. Many clients are embarking on this journey for the first time, which means that their only frame of reference for what therapy is and what it entails is what they’ve seen on TV and in movies, and from experiences with other healthcare professionals like doctors and physical therapists. As the clinicians we are familiar with the process, and meet with clients so often that we can fail to recall that the person sitting in front of us may have no idea what to do next. Shifting into the perspective of a client who has never set foot in a therapists office is helpful in guiding the first moments of contact with a client. I work in a private practice which allows me a certain freedom in how I begin with clients, nevertheless I think my approach can be of use for clinicians in any setting. The following is a spiel that I have memorized and use with every client as a part of the very first thing I say to them after greeting them and escorting them from the waiting area to my office.
“Nice to meet you, again my name is Jacob and I’m one of the counselors here. I just went through your paperwork and everything looks great, thank you for filling that out for me. Typically what I do when I meet with someone for the first time is three main things. First we’ll get a chance to talk more about what brings you here, what you’ve been experiencing in your life and how it’s been affecting you. Then at a certain point in our conversation we’ll shift into sorting out what we’ve been talking about into a kind of framework, or system, that I use. It’s mostly for me, but it’ll help us focus our work together moving forward, and sometimes my clients find it very useful in their own lives. Then the last thing we’ll do is take care of odds and ends, like scheduling, talking about what our next sessions might look like, answering any questions you might have, stuff like that. Does that sound good to you?”
I’ve said this spiel so many times that I can say it in my sleep, and not once has a client disagreed and said “No I want to do this first session differently!” This spiel is vitally important for me in setting up what the first session looks like, but also therapy more broadly. What I’m doing is previewing what is going to happen just minutes from now. I’m also letting the client know that I am the one thinking about the pace of the session and keeping a general track of time. In this spiel I also foreshadow the matrix as a tool that we will use together for our mutual benefit. Right off the bat the client now knows that we will be talking about what brings them in, working together in some way with that content, and then looking ahead to the following sessions.
Notice how I refer to the matrix as “a framework, or system” rather than by name. In truth, none of my clients know the matrix as “the matrix”. When I introduce it to them and in any future sessions I simply call it “our toward and away system”. There’s nothing wrong with calling it the matrix, I simply never have with clients.
After this spiel I ask clients to help me understand what brings them to see me, and from there the work begins. As clients speak I am mostly listening and assessing for certain things. Essentially we are letting our clients tell their story. This is where your unique style will come into play. I use a fairly brief functional contextual interview style to gain more information. If you have certain assessments that you prefer to use during the initial session feel free to continue to do so. The only thing to keep in mind with using the ACT matrix as a part of your intake session is that at minimum you want to reserve thirty minutes for setting up and walking through the matrix for the first time. If you are unable to fit these thirty minutes into your typical intake session then I would suggest saving the matrix for the second session. It was only after practicing the matrix several times with clients that I found a pace that works for me. The process of doing a matrix with clients is an act of history taking and evidence gathering, and much of it will likely overlap with questions you are already asking during intake, so once you are familiar with the matrix you’ll be able to see where it best fits into your way of working.
At a certain point during the history taking process you’ll feel ready to shift into introducing the matrix to the client for the first time. The timing of this is dependent on the context, and will differ from client to client. I typically shift into the matrix once I feel I have a good enough sense of what they are going through and why they have chosen to begin therapy at this time. I tend to take shorter client histories than most therapists I know, but what I do works for me. While walking clients through the matrix you can always ask more questions and follow up with anything you’d like.
Initiating the shift to the matrix is as simple as saying to the client, “I think this would be a good time to start sorting what we’ve been talking about into that framework I mentioned earlier.” At this point I have clipboards and blank sheets of paper at the ready to hand to my client. For the first time the client sees the matrix I prefer to use a blank sheet where the client can draw the entirety of the matrix from scratch rather than use a matrix template. I want the client to feel as though we are working together on something from beginning to end, rather than like I am asking them to fill out a worksheet. I also prefer using paper and pen rather than a whiteboard and marker for this initial matrix so that the client can take theirs home when they finish, and so I can make additional notes on my matrix as needed. There are also a few elements of introducing the concept of the matrix that having it on paper allows me to do more easily.
Face the client with your blank sheet of paper on a clipboard on your lap. The following is my next spiel to introduce what we are about to do together:
“We’re going to be doing a kind of diagram together, it’s super simple, you don’t need any art skills or anything like that. I do mine landscape style, like this (turn clipboard sideways). Just follow along with me. First we’re going to use an example to help us set this up, once we’re finished with the example we’ll put your life and the things we’ve been talking about into it. Okay?”
Every client that I have ever worked with has been okay with this. When I train clinicians on the matrix I sometimes hear things like “I have clients who would never do this,” when I follow up they are often referring to teenage clients or mandated clients. I have and do work with both teens and mandated clients frequently, and none of them have ever been opposed to doing this. I attribute this to setting it up in session one upfront, and relying on building good rapport with the client during the history taking portion. Keep an open mind when introducing the matrix to clients, if they don’t want to do it let them tell you, don’t assume for them that they won’t want to do it.
From here, I ask the clients to draw a straight line across the middle of the page with an arrow on each end. I draw the arrow as I am asking them to do so. A benefit of using a handheld clipboard is that I am able to draw what I need to and then flip the clipboard outward so that the client can see it. The majority of the time I have the clipboard facing the client so that they can follow along with me.