How Can We Make Intakes Suck Less?
There are a lot of barriers to accessing mental healthcare--money, stigma, scheduling, finding competent professionals. There's all kinds of work being done to address these barriers. (For instance, I'm listed in the Open Path Psychotherapy Collective directory, which helps people find therapists who offer sliding scale rates.)
But there's one barrier that's less talked about, maybe because we have almost no idea what to do about it. And that's the burden of having to tell your entire story to a stranger, especially if you've sought therapy before and have already had to tell it numerous times.
I recently attended the Transforming Care Conference on LGBTQ+ and HIV Health Equity, here in Columbus. One of the sessions was about what happens when people encounter inadequate or incompetent mental healthcare and how that affects their likelihood of trying to find services again. Unsurprisingly, the worse clients' experiences were, the less likely they were to try to find something better--even though they needed something better even more urgently.
The presenters offered some possible explanations for this phenomenon, and one of the attendees brought up one that they hadn't considered--if you've already had to share the details of your painful story, and you've received crappy care in response, why would you want to go through the process of baring your soul to a stranger again?
That's a good point. And although I do my best to make the intake process as affirming as possible, I can often tell that my new clients are dreading having to catch me up on everything they've been through.
But unlike some of those other barriers, there doesn't seem to be much we can do about this one. We can make therapy cheaper, more abundant, more accessible, more competent--but we can't exactly keep new clients from having to tell their therapist about themselves because...well, therapy doesn't work otherwise.
And although in private practice we can spread this info-gathering over multiple sessions, those of us working in agencies often have requirements about the data we have to collect right away. Part of this is due to safety concerns--if we don't get into your history of suicidal ideation and you harm yourself after your first session, I've completely failed in my most basic responsibility as a therapist. Another aspect is insurance requirements. Insurance companies want a diagnosis, at least a preliminary one, right from the get-go. They want to see a justification for why they should have to pay for your treatment.
Can we make intakes suck less despite these limitations? I think so. I have some suggestions, first for clients and then for clinicians.
For real, this person is my hero:
For clients:
1. Learn about the intake process.
If you're feeling anxious or overwhelmed at the thought of going to your first therapy appointment and having to answer a lot of questions, it can help to learn more about what typically happens in an initial therapy session. There are a lot of articles out there that cover this in more detail, but here are some things you'll probably be asked about:
what brings you in to counseling--pretty self-explanatory
history of mental health diagnoses or issues
family medical/mental health history
basic biographical information about you--when/where you were born, who's in your family, your education/work history, your current social/romantic/family relationships, your interests and hobbies
any ongoing medical concerns
any events in your life that you'd consider traumatic or life-altering
your patterns of drug/alcohol use
Knowing what the intake process is like can help you manage whatever comes up for you around sharing this type of information with a stranger.
2. Make notes.
Now that you know more about what you'll be asked in your first session, consider making some notes for yourself. Even if you obviously know the answers to those questions, having notes to refer to can help you make sure that you cover what's most significant to you. More importantly, though, writing down some notes beforehand can help lessen the emotional impact of having to share it in the session--you've already written it, it's right there on your phone or a piece of paper. It might seem less emotionally charged that way. The notes don't need to be anything fancy, and you don't have to show them to anyone.
3. Provide documentation.
That said, if you want to, it can help both you and your therapist if you provide some sort of written or visual aid. (For example, the Powerpoint in the tweet above.) While it doesn't necessarily mean you won't end up talking about the contents of it, it'll keep you from having to repeat certain basic facts and will allow your therapist to be more specific and targeted in their questions. It can be easier to answer, "How did your symptoms change after your sexual assault?" than "Was there ever a time when your symptoms changed or got worse?"
By the way, how your new therapist reacts when you provide them with a written narrative, a timeline, or even a Powerpoint about your life is a very good way to assess them as a professional. In my opinion, people whose job it is to help others should be grateful and respectful when the people they're helping try to make it easier by providing supplemental information. If your therapist treats your documentation as some sort of cop-out or an attempt to "avoid" the therapy process, that should tell you something about their willingness to meet you where you're at and make therapy a safe space for you.
4. Set boundaries.
Finally, and most importantly, this is your treatment. You don't have to answer any question you don't want to or get into anything you don't want to get into. Be aware that the less you share with your therapist about yourself, the less they will be able to help you. However, that doesn't mean you have to share everything right away. Therapy can't help you at all if you stop going because you feel unsafe and overwhelmed. You don't have to describe your entire trauma narrative in detail in your first appointment. You can tell your therapist something like, "I have a history of abuse and I'm not ready to go into detail about that now, but please check in with me in a few sessions." Again, their reaction here will be very useful to you in assessing them as a therapist.
For clinicians:
1. Orient clients to the intake process.
Here's one that I know I need to be better at. When we've been doing this for years, we tend to forget how confusing and overwhelming the process of seeking mental healthcare can be for new clients. While most are probably aware that they'll be asked a lot of questions about themselves in their first session, they may not know what we're planning to ask, why we're asking it, or how much input they get to have into the process. Develop an elevator pitch for what intake is and use it to give clients a quick orientation when you meet them. For instance: "This is our first appointment, so it'll be different than our other sessions. I'll be asking you a bunch of questions about your personal and family history, and the issues that are bringing you into therapy. You're welcome to skip any question you don't want to answer right now."
2. Offer options.
Along with telling clients what to expect, you can also give them some options in how to proceed. Even if you're in an agency setting where you have strict requirements about what needs to be asked and filled out during the intake appointment, you could still let your client choose what to talk about first and what to save for the end of the session. For instance, you could ask, "Would you rather start with your personal history, or with what brings you here now?" Being able to choose what to start with (and what to end with) can help give clients more control over a process that often feels very much out of their control.
3. Prioritize the info you need to gather.
If you're in private practice or otherwise have some flexibility in how you do things, ask yourself--what do I actually, seriously need to know right in the first session in order to provide competent, ethical care? That may be a different question than, "What do I need to know to diagnose this client fully?"
As a starting point, you should ask about any potential risk/lethality issues, as well as anything that would cause you to refer the client out to another mental health professional. If you know you're not able to work with certain issues or populations, don't make the client waste their time and money coming back for a second session unless it's really needed. But aside from that, you can let the client choose what would be most helpful for them to discuss in the first appointment. Remember that building rapport by listening and empathizing is just as important as collecting information.
4. Respect clients' boundaries.
This is one that I hopefully shouldn't have to include, but of course I do, because it comes up all the time. No means no. If your client doesn't want to discuss something, don't push it. You can talk "around" the issue--"Are you comfortable telling me more about why that's hard to talk about?"--or you can ask if and how they'd like you to check in about it--"Is it okay if I ask about this again in a few weeks and see if you're able to talk about it then?"
We can have our opinions about the usefulness of therapy when a client won't share important things about their life, but as I said above in my suggestions for clients, therapy won't work at all if a client drops out of it because they feel unsafe or pressured. I've had clients who told me that they've seen multiple therapists in the past and that I was the first one they disclosed a traumatic event to. I've also had clients that I was absolutely certain had some major trauma going on, but never told me. Maybe--hopefully--our therapeutic work helped lay the foundation for them to eventually share their story with someone else they trust. You can be part of that groundwork for someone by respecting their boundaries and meeting them where they're at--and where they're willing to be met.
In short, intakes may always kind of suck, but therapists can help make them suck less. And clients, while it’s our job to do what we can to make therapy work for you, you can still feel more comfortable and empowered by taking some steps to make intakes easier on you, too.
If you have any suggestions for improving intakes, either as a therapist or as a client, please leave them in the comments!