Steps Description Your examples
STAGE 1: STARTING THERAPY
- Greet the patient and establish rapport. Good morning. Thank you for coming today. How are you?
1.1. Receiving the Patient - Introduce yourself and clarify your role as the therapist. My name is Maria, I'm a clinical psychologist
-Explain confidentiality and obtain informed consent, especially in specific Before we begin, I'd like to explain that everything you share here is
circumstances. confidential, unless there is a risk of harm to yourself or other.s
Remember to: Create a warm and welcoming environment to put the patient at ease. (Please take your time to get comfrotable. There's no rush, we will go at your pace.
-Check with patients on expectations combined with a brief description of
how psychologist and patient will work together. Could you tell me what you are hoping to get out of our sessions?
My role is to support you in understanding your difficulties and
- Explain time limits to work with you to find practical ways [Link]'s session will last
1.2. Explaining interview about 50 minutes.
Some people feel unsure or nervous at the beggining,
- Elicit patient’s expressions of concern and initial fear or reluctance.
how are you felling about being here today?
The goal of this interview is to understand your situation better and
- Explain the general purpose of the interview and set the agenda.
decide how we can proceded together.
STAGE 2: BEING IN THERAPY
2.1. GATHERING INFORMATION STAGE
2.1.1. THE OPENING: - Start with general questions to encourage the patient to express themselves What brought you here today? Can you describe in your own words what
Ask the opening question/s to find out freely. has been troubling you recently? When did you first notice something
- Allow the patient to provide an opening statement about their concerns.
the Presenting Complaint wasn't quite right?
Create a Trusting and Empathetic Environment:
- Foster a safe and supportive space for the patient to share their feelings and
thoughts.
- Use active listening and empathy to demonstrate understanding.
Remember to: Use skills for Building a Strong Therapeutic: Relationship:
-Utilize reflective techniques to show empathy and understanding.
Overcome Initial Communication Barriers:
- Encourage open communication and validate any feelings of discomfort or
resistance.
2.1.2. THE BODY:
A. HISTORY OF THE PRESENTING COMPLAINT
How would you describe the symptoms you’ve been experiencing?
When did these symptoms begin, and have they been constant or do they
come and go?
Use open, multiple, leading, and tag questions to explore the patient's Have you experienced something similar in the past?
symptoms/concerns: What tends to make the symptoms worse? And what seems to help, even
slightly?
Have you noticed any physical or emotional changes that occur alongside
these symptoms?
Techniques for Gathering Relevant
Information - Nature/Quality of the symptoms
- Timing: Onset and duration
- Potential Causes
- Previous Episodes
-Aggravating/Alleviating factors
-Associated manifestations
Encourage the patient to express themselves in their own words.
B. PAST MENTAL HISTORY
Personal History What were you like as a child in terms of personality and emotions? How w
Family history ouldanyone
Has you describe
in youryour relationships
family growing
experienced similarup—with family and peers?How has
difficulties?
Exploring the Patient's History and Past medical history your
Do you have any current or past medical conditions? (IF currently
work or academic life been over the years?Do you yes) Havehave a supporttratment forn any health ssues?
you received
Past Psychological history network
Have youorever
close relationships?
Concerns seen a psychologist or therapist before? What kind of treatment do you receive, and did it help?
Do you currently consume alcohol or use any substances?Have y
Drug and alcohol history ou noticed any connection between substance use and how you feel?Are
- Clarify and summarize important points to ensure accuracy. you taking
Let me any medications,
summarise prescribed
what you’ve told me or
to otherwise?
make sure I’ve understood correctly…
2.2. EXPLAINING A TEST OR INVENTORY
I’d like you to complete a questionnaire called the Beck Depression
[Link] consists of a series of statements about how you’ve been
2.2.1. Explain the Beck's Depression feeling over the past two [Link] are no right or wrong answers—just
See document on Canvas
Inventory to your patient choose the option that best reflects your [Link] will help us
better understand the intensity of your symptoms.
This questionnaire measures two types of anxiety: how you feel right now
2.2.2. Explain the State-Trait Anxiety and how you generally [Link] helps us distinguish between temporary
See document on Canvas
Inventory (STAI). stress and more long-term patterns
.Please answer as honestly as possible based on your personal experience.
2.3 . PLANNING THERAPY
Based on what you’ve shared, it seems that your symptoms may be
Associate the patient’s symptoms and characteristics with possible diagnosis, consistent
2.3.1. GIVE DIAGNOSIS with an anxiety-related [Link] example, the persistent worry, physical
describing an initial case formulation
tension, and sleep difficulties suggest this [Link] is an initial
impression, and we will refine it as we continue working together.
Remember to: Include the 3 Objectives for giving and explaining information
One approach we could consider is cognitive-behavioural therapy,
which focuses on identifying and changing unhelpful thought patterns.
Another option might include relaxation techniques or mindfulness
strategies.
CBT is structured and practical, but it requires active participation between
2.3.2. IMPLEMENTATION OF Include the planning and future implementation of a specific therapy
sessions.
THERAPY intervention or technique as appropriate.
Other approaches may focus more on emotional [Link] do you
feel about
starting with weekly sessions focused on these strategies?We can adjust
the plan
depending on your progress and preferences.
- Explain the therapy
- Discuss options and explain advantages and disadvantages
Remember to:
- Negotiate a plan of action
STAGE 3: FINISHING THERAPY
3.1. CHANGE
As we bwgin to close this process, what concerns, if any,
- Review the patient's progress and achievements throughout therapy.
Preparation for Therapy Termination do you have about ending therapy?
- Discuss future support and coping strategies for after therapy. Let's identify the tools you feel confident continuing to use on your own
In what situations do you now respond differently compared to before
- Assess the patient's growth and changes achieved during therapy. therapy?
Evaluation of the Patient's Progress and Which strategies have become part of your routine without needing much
Achievements effort?
I'd also like to hear your honest feedback.
- Obtain feedback on the therapeutic experience from the patient.
What aspects of our work together were most and least helpful?
- Collaborate with the patient to develop a plan for continued support and
growth. If you notice early warning signs returning, what steps will you take first?
Planning Long-Term Support Strategies Let's outline a short, practical plan you can follow during more difficult
- Provide resources and recommendations for ongoing well-being. periods.
I recommend keeping a brief weekly check-in with yourself to monitor
mood and stress levels.
3.2. TERMINATION
The Preventing Mental Health Relapse worksheet
COMMUNICATION TIPS:
Communication During the Therapeutic Process
- Demonstrate active listening skills and full engagement during therapy
Active Listening and Mindful Attention sessions.
During Sessions - Use reflective techniques to show understanding and encourage further
exploration.
- Reflect back on the patient's emotions and experiences to validate their
Reflective Techniques to Demonstrate
feelings.
Understanding and Empathy
- Show empathy and support for the patient's journey.
- Use appropriate body language and verbal cues to convey empathy and
Appropriate Body Language and Verbal
openness.
Expression by the Therapist - Ensure the patient feels comfortable and understood throughout the
session.
Handling Difficult Situations
- Provide a safe space for the patient to express and process intense
How to Manage Intense Emotions from
emotions.
the Patient - Teach coping strategies to manage overwhelming feelings.
- Address any conflicts or resistance that arises during therapy with empathy
Resolving Conflicts and Resistances in
and understanding.
Communication
- Use communication techniques to de-escalate tense situations.
- Prioritize the patient's safety and well-being in crisis situations.
Handling Crises and Emergency
- Have a plan in place to manage emergencies and access additional support
Situations
if needed.
Sources:
[Link]
c-relationship-phases/#therapeutic-alliance
[Link]
of-therapy
[Link]
319336218_Clinical_Interview
[Link]
Mental%20Health%20History%20and%20M
ental%20State%[Link]