An initial consultation is the first step into psychodynamic counselling at Highgate Counselling Centre. Over many years of working as an initial consultant, I have met people of all ages and backgrounds, each bringing something different, but usually sharing a wish to be heard. In this piece, I reflect on how I approach these meetings, what I am listening for, and how decisions about suitability for psychodynamic counselling are made.
My Background and Clinical Experience
I qualified as a psychodynamic counsellor in 2007 having already joined Highgate Counselling Centre as an external trainee in 2005. I became a staff counsellor on qualifying and began working as an initial consultant (IC) in 2008. Since then I have met many prospective clients of all ages and personalities seeking counselling and all very different. The one thing I feel that they have in common is a need to be heard, perhaps for the first time in their lives.
What the Initial Consultation Is —and Is Not
This is to assess whether a person is suitable for psychodynamic counselling. They may be highly intelligent and qualified in their field of expertise but not necessarily be suitable for the counselling that we offer at HCC. During a lengthy meeting – sometimes it take over two hours – I need to establish in my mind whether the person opposite me may benefit from this type of counselling. It is important to say that we do not know the client.
It can take much courage for someone to apply for counselling in the first instance and we, as ICs on behalf of the Centre, have a responsibility to gauge their suitability. We will obtain a lot of factual information in that meeting but we should also get a feeling of whether they are “right” for on-going work. For this we depend to a very large extent on our countertransference, which is a key part of the report that we prepare for the allocations manager/director. The latter provide support for the ICs, who do not make that final decision as to whether a person will be offered a place at the Centre. However, the allocation is very much dependent on our reports. We will make recommendations as to whether short- or long-term counselling is appropriate but we will also state our concerns, if any, on the basic premise of suitability for psychodynamic counselling.
What Happens During an Initial Consultation
So how is this done? Although the report has a number of headings of information, each of the ICs in the team will have their own style on how to go about it. My own has been honed over many years of conducting these meetings and I follow the order of these headings. Unlike in private practice, where the assessment process may take a few sessions of normal length, we are required to write a report after having had one extended session. These first sessions in private practice may be like any normal session, with the history unfolding within the transference, and it may be that notes are unnecessary. I know that I will never remember all the detail in my meetings at the centre and I scribble throughout.
At the outset, I welcome the prospective client introducing myself, telling them the purpose of the meeting and how it differs from a normal counselling session, including the length of the meeting. They will have been told this by the receptionist when making the booking but people forget. It is important to tell them that I will not be their on-going counsellor —although it can happen in rare circumstances— and that it may take some four to five weeks before they hear from their allocated counsellor offering them their first appointment.
After finding out why they are seeking counselling and, very importantly, why now, I prepare the genogram. This can generate much emotion including, for example, shame and embarrassment that they cannot remember their grandparents’ names. This is not a therapy session so I try to put the client at their ease at moments of distress. Quite often I refer back to the genogram during the meeting to check a detail that I was unsure about. On one occasion, the client referred to his wife later in the meeting whom he had not mentioned when I had been drawing up the genogram. I duly adjusted it and we spoke briefly about his forgetting to mention her which I highlighted in my report. On another occasion, when preparing the genogram for a young man, I asked him for the names of his parents. He said “Well, you know them!” To say I was thrown is an understatement. He explained who they were and then I remembered that my wife had worked with his father with whom I had played golf years earlier and that we had met them at a party perhaps 10 or 15 years ago! They had spoken of their son but seeing his name on a registration form today all those years later had meant nothing to me. I apologised and said that, because of this, I could not continue with the meeting and that we would rearrange it at no extra cost. Fortunately for me, he understood and did not give me a hard time. This has happened to me only once in over 300 meetings but one needs to be aware of the possibility.
Whilst obtaining details of their history, present circumstances, illnesses, previous counselling and therapy and any other relevant information, I have in the back of my mind how I am feeling as I sit with the client. For instance am I interested in them and would I like to take them on as a client given the opportunity? It is important to remember when one comes to complete the section on countertransference after the meeting that what you say are your feelings and not the client’s.
If I am unsure about whether the client should be offered a place, I tell them that, because, say, of their history, we might need to see them again to help us decide. Usually they understand and happily this does not happen often.
I ask them what type of counselling they feel they would like, i.e. long or short term. Some know but many do not. I then tell them what I feel would be appropriate and why and generally we agree. In obtaining their availability I mention that missed sessions have to be paid for. This quite often leads to a discussion but hopefully they will remember this when their on-going counsellor reminds them.
Finally, I ask them if they have any questions for me. Quite often they ask what might happen if they do not get on with their counsellor. I suggest that initially they should speak to their counsellor about this to try to understand what might be going on which would probably be transferential. If the problem cannot be resolved they would be allocated another counsellor.
At the end of the meeting I thank them for coming in and show them the way out.
Final Reflections and the Reality of the Unexpected
One can never be sure who will come through the door but one needs to be open to anything. More often than not, the people coming to the centre are not suffering from a mental disorder but have issues for which they need help. We do not offer cures or provide solutions; we do not offer guidance or reassurance. So what do we provide? We offer them a space to talk to enable them to gain insights and understanding into their difficulties and to help them manage their lives better. I tell this to clients at the outset of the meeting so that they are in no doubt as to what to expect. Their reaction will also help me to get an idea of their suitability.
One last story: It is very rare that someone comes to the Centre with another. I tell this story as it is, I feel, important to know who is seeking or wants counselling. The following has happened to me just once: The gentleman supposedly seeking counselling came in with his partner who remained in the waiting area whilst we undertook the meeting. He was from a recent war zone and, from his initial words, it sounded as though he had been in the war and may have witnessed some terrible things. We were working on the genogram about half an hour into the meeting when he said “Stop. I don’t want to go on with this. I don’t want you to write a report so tear that up.” I am not sure if I did the right thing but, guided by my feelings, I tore up the report and put my pencil down. I said “Okay, no report. But we have some time left. Would you like to talk a bit more?” He said he would and I listened to some harrowing material. At the end of the meeting I went out with him and his partner stood up looking at me as if to say, I felt, “Will you take him on?” At the same time, I saw him shake his head to her as if to say “This is not for me.” They left and I felt that it was she who had wanted him to have counselling whereas he was not ready to embark on it. I felt terribly sad as they left the building.
