Why the First Session Decides Everything

Wrtitten by: Jon Hook, MA

Why do so many people never come back?

Up to half of all clients drop out of therapy prematurely, and many leave after just one session. For some, that first visit is enough. But for most, leaving early means missing the chance to really benefit. The uncomfortable truth is that therapists don’t just lose clients because they’re “not ready.” Often, it’s because the first meeting failed to give them a reason to return.

The problem with the traditional intake

The standard intake—long forms, exhaustive histories, lots of note-taking—can make the first session feel like paperwork instead of therapy. Clients come in looking for hope, relief, and connection, and too often they get a questionnaire. As Daryl Chow argues in The First Kiss, we’ve mistaken data collection for building momentum. The cost is that people don’t come back.

What makes a first session work

Research shows that the first session is the make-or-break moment. When clients return, it’s often because:

They felt hope. The therapist connected their story to a believable path forward.

They felt heard. The therapist didn’t just collect information but summarized, checked understanding, and invited correction.

They felt fit. Goals and next steps were agreed on together, not imposed.

They got a win. A small, immediate tool or idea signaled that change was possible.

In short: people come back when the first meeting feels like therapy, not a screening.

Getting what they came for

Therapists often tell themselves stories about why clients don’t return: they weren’t ready, they were resistant to change, you can’t work harder than the client. These explanations make us feel better, but they often miss the point. People come because they want something—even if it’s small—and if they don’t see a step toward that thing, they don’t return.

I once saw this firsthand in training. A man with a thought disorder came to a free clinic because he lost his notebook, which he believed contained groundbreaking physics. Maybe it was. He’d heard the clinic could help. The session itself was picture-perfect: empathic listening, skillful reflection, a textbook alliance. But when he filled out the end-of-session feedback form, the scores showed he was unlikely to return.

With only seconds left, the clinician asked, “What could have made today better?” The client paused and said, “You’re a really nice guy and you listened to me, but I came here because I lost my notebook.” The therapist had 30 seconds to save the relationship. And he did—by offering to help him find the notebook, or to get him a new one.

That was the turning point. Not a brilliant intervention, not a breakthrough insight—just a simple act of hospitable, outside-the-box thinking. It was exactly what the client came for. And it likely saved not just the first session, but the possibility of every session after.

Learning from older traditions of welcome

We don’t have to invent this from scratch. Many older traditions show us how to welcome someone into a new space. In Native American hospitality, the guest is treated with dignity from the moment they arrive—assumed to be weary, vulnerable, and deserving of care. In monastic communities, strangers are received as blessings, oriented gently to an unfamiliar environment rather than dropped into it. In the Orthodox Christian tradition especially, monks are taught to freely house, clothe, and feed every visitor because you never know who might be an angel in disguise, testing the spirit of the cloister.

All of these traditions remind us that people are whole contexts, not blank slates. Therapists can learn from this: begin with small acts of welcome, set a pace that matches the client, and orient them softly into the strange world of therapy. Like these traditions, our first task is not to analyze but to host—creating a safe, respectful space that invites return.

The role of feedback

Here’s where feedback becomes essential. Therapists who ask clients—right away—“What wasn’t helpful today?” or “What would you like to be different next time?” see better retention and outcomes. Effective therapy isn’t about racking up glowing feedback. It’s about creating a space safe enough for clients to say, “That didn’t work for me.”

In fact, research on so-called “supershrinks” shows they weren’t special because they had the best techniques. Many weren’t even aware of their unusual effectiveness, and their sessions didn’t look polished. As Scott Miller once told me in a training, “some of their tapes looked like shit.” What set them apart was that clients felt safe telling them when things weren’t working, and the therapists listened, adjusted, and tried again.

The takeaway

The first session is not an intake; it’s an invitation. People come back when they feel hope, when they feel heard, and when they believe therapy is something that can actually help them. And more often than we like to admit, it’s about whether they got what they came for—even if it looks small from the outside. Feedback isn’t a stack of forms—it’s the lifeline that lets therapists turn mistakes into progress.

So here’s the real test: are you willing to ask your clients how it’s going—and brave enough to change when the answer stings?

Sources

1. Swift, J. K., & Greenberg, R. P. (2012). Premature discontinuation in adult psychotherapy: A meta-analysis. Journal of Consulting and Clinical Psychology, 80(4), 547–559. https://doi.org/10.1037/a0028226

2. Simon, G. E., & Imel, Z. E. (2012). Is dropout after a first psychotherapy visit always a bad outcome? Psychiatric Services, 63(7), 705–707. https://doi.org/10.1176/appi.ps.201100250

3. Miller, S. D., Hubble, M. A., & Duncan, B. L. (2007). Supershrinks: Learning from the field’s most effective practitioners. The Psychotherapy Networker, 31(6), 26–35, 56.

4. Okiishi, J., Lambert, M. J., Nielsen, S. L., & Ogles, B. M. (2003). Waiting for supershrink: An empirical analysis of therapist effects. Clinical Psychology & Psychotherapy, 10(6), 361–373. https://doi.org/10.1002/cpp.383

5. Chow, D. (2018). The First Kiss: Undoing the Intake and Igniting First Sessions in Psychotherapy. Better Outcomes Now Press.