Despite the fact that the initial interview is not one of the topics that are often handled independently, it has its own specifics and differs from other psychotherapy meetings. Due to the number and complexity of the factors involved in therapeutic work, it is difficult for novice therapists to navigate them and use the input data for the further course of treatment. The paper focuses on the period of the beginning of therapy and the conclusion of the therapeutic contract and its circumstances, which represent the starting point for therapeutic work, just as the relational environment represents the starting point for the development of the individual.

In the past, there have been efforts to investigate the use of psychotherapeutic techniques, but according to Řiháček and Roubal (2019), this is a relatively little-researched area. Several factors affecting the cooperation between the therapist and the patient enter the therapeutic process. In a study focused on psychoanalytic psychotherapy, Mintz, Luborsky and Auerbach (1971) describe three determinants of the method: optimal empathic relationship, directive mode and interpretive mode.

Currently, attention is also being turned to the neuroevolutionary origin of emotions and needs, since change is not always possible to achieve only through cognitively oriented techniques, for example interpretation. By identifying the systems affected by early experiences, the patient's experience can be better understood. Panksepp and Biven (2021) link psychotherapy with neuroscience through motivational-emotional systems (seeking, pleasure, care, anger, fear, panic, and play), thereby contributing to a deeper understanding of affective processes.

Psychoanalytic treatment does not have uniform procedures in approaching the patient. It is necessary to take into account the level of organization of the personality, the life history and the structure of the patient's personality. McWilliams (2015) points to the need to adapt the approach to the individual functioning of the patient — for example, paying more attention to boundaries or emotions according to the nature of his difficulties. Recently, there has been an increase in the number of patients with borderline personality organization, which is addressed by Fonagy and colleagues (Bateman & Fonagy, 2004; Fonagy & Target, 1996), who develop treatment approaches focused on mentalization based on psychodynamic directions. It is therefore important to understand the patient's individual way of thinking in order to feel understood.

In the first sessions, the therapist obtains both objective and subjective information. The first meeting is usually accompanied by anticipation, curiosity and uncertainty on both sides and belongs to the demanding parts of therapeutic work. In particular, it requires:

  • understanding the patient's situation,
  • assessment of the patient's suitability for psychoanalytic psychotherapy,
  • restraint in expressing one's emotions,
  • flexibility and sensitive response to the patient.

In the initial phase of treatment, the therapeutic alliance is still being formed, and its future also depends on the patient's current motivation to continue cooperation. Psychotherapy is a voluntary process and a working relationship may not always be established; even minor interactional disagreements can lead to termination of treatment, but at the same time they provide important diagnostic material (Eubanks-Carter et al., 2024).

Pre-therapy period

If we talk about the beginning of therapy, we cannot ignore the fact that the patient already creates a certain conscious or unconscious idea about the therapist when arranging the appointment. Information about how he learned about the therapist, whose recommendation he comes to and with what motivation he enters the treatment, has an impact on further cooperation between the patient and the therapist. An important aspect is also the interval between the appointment and the first meeting — with a longer time interval, some of the interested parties will not arrive, and those arriving may experience disappointment or unconscious resistance (Klimpl, 2005). At the same time, the patient's first reactions to the therapist represent the beginning of the formation of a therapeutic alliance, while the subjective experience of contact already in the initial meetings is significantly related to the assessment of the quality of the session and further cooperation (Stefana et al., 2024).

Like the patient, the therapist also perceives the pre-therapeutic period. The way the patient reports, whether he makes an appointment himself, his communication style, level of formality, questions or reactions to the offered appointments provide the first information about his relational functioning. Based on them, a preliminary idea of ​​the patient begins to form, which is subsequently adjusted during subsequent meetings.

Contact before the first session also creates space for the therapist's internal preparation for the arrival of a new patient. Clinical experience shows that if the therapist does not have enough space for psychological attunement, this can manifest itself in subtle communication signals, to which the patient reacts with a reduced level of engagement or an early termination of cooperation. At the same time, research shows that patients with higher relational sensitivity and burden from early experiences react more significantly to the quality of interpersonal adjustment (Nowak et al., 2024).

The departure of patients from therapy is also a consequence of their relationship dynamics. The phenomenon of escape from treatment was dealt with by McWilliams (2015), who described the types of people with this tendency. At the initial meeting, it is therefore advisable to keep the frightened patient in therapy in mind. An emotional bond with a therapist can be intimidating, for example, for people who have experienced unreliable or hurtful closeness — the moment the therapist's warmth activates the need for dependence, anxiety and a tendency to break off the relationship can appear.

At the same time, people defending addiction may have a problem in creating an emotional bond with the therapist, and the denial of the need for care, which is linked to their self-esteem, can be solved by early termination of therapy. They subsequently rationalize their escape from treatment, because the recognition of the emotional importance of the other person is usually accompanied by a feeling of shame. Early relationship experiences influence the ability to regulate closeness and cooperation in therapy as well as the speed of therapeutic improvement (Nowak et al., 2024). Fluctuations in motivation or a tendency to cut off contact can be the first signs of a relationship breakdown. The way in which this situation is grasped therapeutically is important for the further development of cooperation (Eubanks-Carter et al., 2024).

Entry interview

The need not to get lost during the first meeting with the patient and at the same time to capture the dynamic connections of his problems led to the emergence of diagnostic schemes based on psychoanalysis. The initial interview can take place in different ways, and the therapist chooses the one he considers effective and is identified with. The authors Holub and Telerovský (2012) mention, for example, Deutsch's associative anamnesis, Sullivan's structured "participant observer" interview, identification of the patient's motivation for treatment according to Gill, Newman, and Redlich, or Bálint's diagnostic interview exploring the interpersonal relationship and meaning of transference. It is also possible to assess the level of personality organization through a structural interview according to Kernberg. Argelander (1998) draws attention to the scenic aspect of the first interview.

The initial interview can resemble an exploratory-medical model summarizing the information obtained and resembles a psychiatric examination, where the patient answers the therapist's questions. At the opposite pole is the relational-dynamic model, in which the therapist also observes scenic situations and pays attention to the patient's unconscious reactions (Telerovský & Holub, 2012). Most often, the first meeting takes place as a semi-structured interview, i.e. a combination of these approaches.

In therapeutic work, the feeling of the therapist is important, through which he can respond empathetically to the patient, mediate the therapeutic framework and establish a culture of cooperation so that the patient understands it and is able to accept it. This is a challenging task not only for the therapist, but also for the patient, who encounters a lot of new information and often comes in an emotional state with a reduced ability to concentrate, especially if it is his first experience with therapy.

From the point of view of Bowlby's theory of relational attachment (Bowlby, 2023), the therapeutic framework and the regularity of meetings represent a safe base. Consistency, availability, the ability to respond adequately to the patient's signals and respect for the need for autonomy are required from the therapist, which can lead to a corrective emotional experience. The importance of the quality of the relationship is also confirmed by more recent research, according to which early relationship experiences influence the ability to cooperate in therapy and the pace of therapeutic improvement (Nowak et al., 2024), while meta-analyses long-term point to the importance of relationship factors in the effectiveness of psychotherapy (Hašto & Biesčad, 2006).

Psychoanalytic psychotherapy is not a set of techniques that are the same for every individual and is not suitable for everyone interested in treatment. When working with the patient, it is necessary to take into account his individual needs, define the conflict or deficit he comes with, and evaluate his capacity for introspection and insight. These indicators subsequently influence the way of interventions so that they are bearable for the patient. As McWilliams (2015) states, it is essential to recognize the differences in the depth and extent of personality problems, set realistic expectations and adapt the therapeutic approach accordingly.

In clinical practice, it may happen that the patient enters the treatment with an ambivalent attitude towards closeness and the rules of cooperation. Difficulties with following the framework may then not only represent an organizational problem, but also a manifestation of relational dynamics, for example sensitivity to rejection or expectations of non-acceptance. The patient's reactions to the conditions of the treatment thus provide information about his inner experience and can also lead to premature termination of cooperation. At the same time, research shows that patients with a higher developmental burden react more sensitively to the relational conditions of treatment (Nowak et al., 2024).

Anamnesis

For a better understanding of the depth of the patient's difficulties, determination of a preliminary diagnosis and familiarization with the reality in which he lives, it is necessary to obtain anamnestic data. Most patients are initially able to answer relatively directly even to intimate questions regarding, for example, sexuality or alcohol consumption, since the therapist is initially perceived as a stranger. With the development of transference processes, answering may become more difficult - the patient may experience fear, shame, infatuation or other feelings towards the therapist arising from his relationships with close people. This also confirms the functioning of transference and the fact that the patient's perception of the therapist is not completely realistic (Klimpl, 2005; Mitchell & Black, 1999). It is useful to work therapeutically with these manifestations and help the patient gain insight.

When processing anamnestic data, the therapist should be oriented in the patient's reality and have a basic understanding of his difficulties. The five-axis model (Kessler, Stasch & Cierpka, 2013) can help systematic grasping:

  • OS I – Experiencing difficulties and prerequisites for treatment. It includes the patient's motivation, referral to psychotherapy, perception of the disease, duration of symptoms and expectations from treatment.
  • OS II – Interpersonal relations. Mental disorders can also be understood as relationship disorders; maladaptive interpersonal patterns significantly influence psychological distress. It is monitored how the patient perceives himself and others and how he is perceived by the environment.
  • OS III – Psychodynamic conflicts. It assesses intrapsychic conflicts in central areas of life (partnerships, family, profession, group situations).
  • OS IV – Personality structure. It captures the level of personality organization according to Kernberg (well integrated, neurotic, borderline, psychotic).
  • OS V – Mental and psychosomatic disorders. It is based on the ICD or DSM classification systems and links psychopathology with the patient's symptoms.

The data obtained in this way make it possible to link current symptoms with the patient's personality functioning and developmental history, which are also important in terms of the course and pace of therapeutic change (Nowak et al., 2024).

Empathy

Empathy is a term often used in colloquial speech, while it tends to be simplified. In psychotherapy, however, it represents one of the basic pillars of the therapeutic relationship. According to López and Grau (2011), it is the ability to empathize with the patient's experience and at the same time convey this understanding to him in a comprehensible way so that he feels understood. The therapist thus reacts not only to the obvious content of the statement, but also to the meanings that the patient communicates latently.

Communication with an empathetic approach takes place in several ways:

  • active listening accompanied by signals of understanding,
  • by focusing on semantically and emotionally important topics,
  • questions aimed at clarifying the meaning of the statement,
  • paraphrasing and summarizing,
  • by reflecting feelings, including those that remain at the level of preconsciousness (Ruiz & Villalobos, 1994).

Empathy is not sympathy or compassion. In addition to the emotional one, it also has a cognitive component, so it is necessary to understand the ideological origins of the patient's feelings and at the same time maintain the distance necessary for objectivity (Fernández et al., 2012). The therapist does not have to agree with the patient's beliefs, even if he understands their meaning. The healing factor is the relationship itself, in which the patient can express his experience and gradually understand it (López & Grau, 2011). At the same time, patients evaluate the quality of the session mainly according to the degree of understanding and emotional tuning of the therapist, not only according to the content interventions (Stefana et al., 2024).

At the same time, empathy means the ability to work with the therapist's own reactions. Intense feelings, such as anger or rejection, may appear during the session, which are part of relational dynamics and require regulation (Fernández et al., 2012).

Humor

Humor can be a useful component of therapeutic communication, although its use is less often discussed. It helps reduce tension and promote contact if it arises naturally from the situation (López & Grau, 2011).

From a psychoanalytic point of view, humor represents a defense mechanism of a higher order — unpleasant affect is not denied, but transformed into a tolerable form while maintaining the reality of the situation (Christoff & Dauphin, 2017). Thus, humor does not deny suffering, but allows it to be experienced without being overwhelmed.

The condition for its effect is relational tuning. Premature or insensitive use may be perceived by the patient as belittling or defensiveness of the therapist (Christoff & Dauphin, 2017). Therefore, it is recommended to use humor sparingly, especially in the initial stages of therapy (López & Grau, 2011).

At the same time, humor can signal the ability of the psyche to create distance from one's own experience and thereby support symbolization (Christoff & Dauphin, 2017).

Neutrality

Neutrality has been interpreted differently in psychoanalysis. Kernberg (1976) introduced the concept of technical neutrality as an attitude that allows genuine interest in the patient while preserving his autonomy.

According to Anna Freud, neutrality means maintaining equal distance to the Id, Ego and Superego (Mitchell & Black, 1999). Thus, the therapist does not support impulse or prohibition, but maintains a position of exploratory curiosity.

Schafer (in Greenberg, 1986) describes the neutral stance as the ability to allow conflicts to be expressed without favoring one side and without the therapist pushing for solutions.

Therefore, neutrality does not mean coldness or the absence of a relationship, but a regulatory principle of therapeutic work that, together with empathy and the sensitive use of humor, creates the conditions for the patient's own understanding (Kernberg, 1976; Mitchell & Black, 1999).

Conclusion

The initial interview in psychodynamic psychotherapy is not only a diagnostic phase, but represents the first regulation of the interpersonal distance between the patient and the therapist, which determines the emergence of a therapeutic alliance and thus the further course of treatment. The beginning of therapy significantly affects its continuation. The initial meeting is the space in which the therapist begins to orientate himself in the patient's difficulties, expectations and way of relating, and at the same time the patient's first experience with the therapist's way of working arises.

If this phase is based mainly on intuitive guesses, situations may arise in cooperation that remain unclear for both parties and sometimes lead to interruption of treatment. The first meetings are naturally accompanied by uncertainty: the patient enters an unfamiliar environment and the therapist encounters a new psychological world. Even the contact before the first session, reactions to the framework and the course of the conversation itself bring information about the regulation of closeness, expectations and ambivalence towards cooperation. Their capture and naming can help clarify the therapeutic contract and stabilize cooperation.

The purpose of the post is to bring closer the circumstances of the beginning of therapy and to support their awareness on the part of the therapist. The initial interview can thus be understood not as a formal entry into treatment, but as the first step of the therapeutic process, in which an understanding of the patient and the basis of the working relationship are simultaneously created.

Author: Mgr. Radka Nguyen

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