DBT Nightmare Protocol

For a new client (and therapist), the first session can carry plenty of unspoken questions: What am I expected to share? Who will hear about it? What if I’m not ready to talk? Before exploring what brought someone through the door, therapists have an opportunity to make the process clearer, and invite the client into a working partnership. A thoughtful introduction brings together warmth, informed consent, professional boundaries, and client choice. For provisionally licensed counselors, it also means explaining supervision in a way that feels transparent and reassuring. The template below offers a starting point for that conversation. Adapt it to your voice, your practice’s policies, and the person sitting across from you, leaving room for questions along the way. “Hi, I’m _____, a provisional licensed professional counselor in Missouri. I’m glad we could find a time to meet. “You mentioned _____ in your intake paperwork. Today, I’d like to understand those concerns in your own words, learn what you hope will change, and talk together about how I can help. “Before we begin, I want to review a few things about counseling. I practice under the clinical supervision of _____, LPC. My supervisor reviews my clinical work, and we may discuss your care and review relevant records as part of that supervision. “Counseling can help you understand patterns, develop skills, and work toward changes that matter to you. Sometimes discussing difficult experiences brings up uncomfortable feelings. You can tell me when something feels overwhelming, ask to pause, or let me know when an approach is not helping. “Your privacy matters. What you share is confidential, with certain limits explained in our consent paperwork. These include legally required reports of suspected abuse or neglect, situations involving serious safety concerns that may require protective action, and disclosures required by applicable law or a court order. If a legal request for information comes in, we review the requirements before responding. Whenever possible and appropriate, I will discuss a necessary disclosure with you first. “You can talk openly about thoughts of suicide or harming yourself. Having those thoughts does not automatically mean hospitalization; I will ask questions so we can understand your safety needs and determine the appropriate support. “I use _____ approaches. I’ll explain what I recommend, why it may help, and any relevant risks or alternatives. You can ask questions, decline an intervention, and give me feedback. “You’re in the captain’s chair when it comes to your goals and choices. My role is to bring structure, clinical guidance, and attention to safety. We’ll develop a treatment plan together and revisit it as your needs change. If we find that another therapist or service would better meet your needs, we can discuss that and appropriate referrals. “[Review session arrangements, fees, communication boundaries, emergency procedures, and any setting-specific confidentiality policies.] “What questions or concerns do you have about what we’ve reviewed? Are you comfortable proceeding? “What brings you here at this point in your life, and what would you most like help with?” Additional checkboxes: For the remaining first-session checklist, I would add: ☐ Session length, frequency, fees, insurance, and cancellation expectations. ☐ How to contact the therapist, expected response times, and what to do during an emergency or outside office hours. ☐ How records are maintained, who can access them, and any applicable billing disclosures. ☐ Questions, understanding, and documented consent to proceed. ☐ When applicable: telehealth location/privacy/disconnection procedures; guardian involvement and minor confidentiality; couples/group confidentiality policies; mandated treatment and what gets reported to the referring party. ☐ Separate explanation and consent for recording or observation, if used. A clear introduction sets the stage. How you manage the rest of the session helps turn those words into a therapeutic experience. Here are ten practical tips for keeping initial sessions welcoming, purposeful, and within the allotted time. Set a flexible agenda together. Briefly explain what today will include: introductions, informed consent, understanding the client’s concerns, and identifying next steps. Ask what the client most wants to make sure you address. Maintain a steady cadence. Give clients room to think, feel, and respond while keeping an eye on the clock. Use gentle transitions rather than rushing through questions or allowing the opening discussion to consume the entire session. Make time checks collaborative. Try, “We have about twenty minutes left. What feels most important to spend that time on?” This helps clients participate in prioritizing the conversation. Prepare the client for the ending. Offer a reminder about ten minutes before the session ends, then begin closing with enough time to summarize, check emotional readiness, and discuss next steps. A predictable ending helps prevent the client from feeling abruptly cut off. Be thoughtful about opening difficult material late in the session. If a significant concern emerges near the end, acknowledge its importance and assess immediate needs. Collaborate on what can be addressed today and what needs dedicated time next session. Safety concerns require appropriate assessment and action regardless of the clock. Take concise, precise working notes. Capture clinically relevant themes, meaningful changes, interventions provided, the client’s response, and follow-up needs. Brief phrases can support accurate progress-note writing later without turning the session into a transcription exercise. Store all notes according to practice policy and privacy requirements. Keep your attention with the client. Explain why you may jot down a few notes, maintain natural eye contact, and pause writing during emotionally significant moments. Your notes should support your presence in the room. Check understanding in small pieces. Pause during the introduction and informed-consent discussion. “What questions does that bring up?” often invites more conversation than “Does that make sense?” Give the client space to clarify concerns before moving on. Reflect before moving to solutions. Summarize what you understand and ask whether you have it right. Initial sessions can feel crowded with assessment tasks; a brief reflection helps the client feel heard and keeps your clinical understanding grounded in their experience. Close with a shared summary and a clear next step. Identify the main themes, ask what felt useful or difficult, and agree on the next focus. Confirm scheduling and any between-session plan. Complete the progress note promptly afterward, while your recollection is fresh. Use OARS to keep the conversation collaborative. Incorporate open-ended questions, affirmations, reflections, and summaries throughout the session. Balance questions with reflections so the client feels heard rather than interviewed. Affirm specific strengths and efforts, and use summaries to check your understanding and transition between topics. Maintain an ongoing mental status lens. Quietly observe the client’s presentation throughout the session, including appearance, behavior, speech, mood and affect, thought process, attention, and orientation. Integrate these observations naturally rather than treating the Mental Status Examination (MSE) as a separate interrogation. Ask direct questions when clarification is needed, and document only what you observed or assessed; areas such as thought content, perception, and safety cannot be established through observation alone. Begin developing a diagnostic formulation. Organize the information gathered into possible explanations for the client’s concerns. Consider symptom duration, severity, functional impact, history, cultural context, and potential medical or substance-related contributors. Keep early impressions tentative, distinguish the client’s report from your observations, and identify what additional assessment is needed. Bring diagnostic questions and competing explanations to supervision rather than rushing to a conclusion. The first session does not need to answer every question or uncover every part of a client’s story. It should give the client a clearer understanding of counseling, an opportunity to feel heard, and a voice in what happens next. For developing therapists, balancing connection, assessment, documentation, and time takes practice. Use this introduction and these tips as a flexible guide, then bring your questions and observations to supervision. Notice what helped the conversation flow, where you felt rushed, and what you want to approach differently next time. Aim to end the session with the client knowing three things: what to expect, how they can participate, and that their concerns have been taken seriously. Geries Shaheen is a Licensed Professional Counselor and Nationally Certified Counselor operating in and around St. Louis Missouri. Geries holds his MA in Professional Counseling from Lindenwood University, BA in Intercultural Studies from Lincoln Christian University, and holds a certificate in Life Coaching, Geries provides life coaching services to clients online globally. Geries is EMDR trained and DBT Certified, practicing from a TIC lens.