Sunday, August 28, 2011

7 things to do during your first therapy appointment

I have a friend who is returning to therapy after a long time away. She's understandably a little nervous about the whole thing - one of the things I always try and remember is that even though therapy is a comfortable situation for me, a first visit is often anything BUT for my clients. She asked for some ideas about what to do, and what to expect, on a first visit. Being the accommodating type, here they are!

1. Spend a little time preparing. Sit down with some paper and a pen (whoa! Old-fashioned! Keyboard, tablet or phone works just fine, as well) and do a 5-minute free-write about what is on your mind, and about what your therapy goals are. Or, make a thought map by writing random words with your non-dominant hand. Free-associate. Make a spreadsheet. Bake a cake and pipe your goals onto the icing. The point is, rather than just walking into the therapy room and going "oh, uh, what now?" just invest some time in thinking about what you want out of this therapy thing. It is ABOUT YOU. Let's repeat this - therapy is ABOUT YOU. One of the things that makes people nervous about therapy is wondering how to do it right, or how to please the therapist. This will result in less progress and more frustration. Quiz time: Therapy is about ___. Right!

2. Realize that your therapist has some basics that need to be covered. We all do it a little differently, but we all have some things we have to take care of. You'll go through a process that we call "informed consent." This is an ethical obligation of ours. You'll be told about your rights of confidentiality, and about times that your therapist might need to break confidentiality (short version - life-threatening emergency, imminent suicidal risk, some court-related things that most likely won't happen to you). Your therapist will hopefully explain his or her policies about attendance, cancellation, etc. At some point, they'll do a risk assessment, in case one of the reasons you're in therapy is due to suicidal thoughts or intentions. At this point, if you have questions, ask them. It's always so refreshing when someone asks questions after the informed consent process!

3. Get a feel for the relationship. This one is a little tougher to explain in words. As I've said a few times around here, and will say a lot more, the relationship is critical to getting good therapy work done. If you are uncomfortable, don't feel safe, or just don't feel that connection, you're really going to have to force the work, and that's not what you're paying for. Sometimes it is immediately apparent that your therapist is not the one for you - in that case it's absolutely fine to simply say "I don't think I'm going to return" at the end of the session. "We just don't click" is not a bad thing for us to hear. I'd so much rather hear that than struggle through a few sessions with a client who is obviously not feeling the connection. If you're into humor, tell a joke or see if your therapist tries to. Some people want a concerned mortician to talk to. None of my clients are those people. It might not be a night at the comedy club, or a conversation with your best friend, but you'll know if it feels right. If it doesn't, then one and done is fine.

4. Go ahead and trot out that "one thing." Yeah, easy for me to say! I have this theory that everyone has at least one thing that they're sure nobody can accept, or they've been conditioned to think that it's bad or wrong. At least one. I've gone months with people before they've told me that they spend the majority of their time off going to swing clubs and being bound and gagged, or that they're Republicans, or, you know, whatever. And after they tell me, things shift. They've gotten That One Thing out on the table, I've accepted it, and we've moved on. You don't have to spend the entire session talking about the fact that you've lost your last three jobs due to your obsession with Papa Smurf, but maybe just drop a hint. Your therapist will be okay. If your therapist is not okay, and gasps disapprovingly, GET OUT NOW. Really, don't even wait until the end of the session. Therapy is where That One Thing is something that can be talked about. That One Thing is a part of you. A good therapist values all of your parts.

5, Set some goals, but realize that things change. Sometimes one of my clients will express amazement at my lack of whiteboard, or the fact that I haven't made a goal list and set deadlines. Here's the thing: So many times, a client will tell me what they want to work on, or what their goals are, and when I go back at the end of our work together, those goals have been left far behind, abandoned for whatever has become more important to them. Figuring out how to survive your crazy boss suddenly becomes a non-issue when your boss gets hit by a meteorite (okay, no personal experience with that one). Lives change. Minds change. Superficial goals are replaced by the ones that you find when you start to find yourself. This is one of the most beautiful things about therapy work. Come in with your list, but be prepared to burn it ceremonially, or maybe just chuck it in the shredder.

6. Make sure your therapist checks in. A good therapist will check at the end of the session, and throughout your work together, to make sure you are feeling comfortable (or at least aware of why you are uncomfortable) and safe in session. They will assess in an ongoing basis how you are doing on your goals, whether you are making progress, and how you feel about the therapeutic relationship. If you finish your first session, and your therapist doesn't at least ask if the match seems okay, then listen for it at the beginning of your next session. If they skip past this, then ask them why. Some therapists, believe it or not, have a tough time with some of the necessary work of building the therapy relationship. Make sure that your therapist isn't one of those.

7. End with some adjustments. Screw up your courage and make a suggestion or two. "I'd be more comfortable if we could spend more time chatting at the beginning." "I noticed you checking your watch and wonder if that's necessary." "I realized that I don't really want to talk about my mom yet." Whatever you've got. Hopefully your therapist will do number six above, and give you some time to just relax and reflect on that first session. If the two of you can do that together, you're on your way to good work.

There are plenty more suggestions all over the internet, if you'd like to do some more reading. That counts as preparation! The bottom line is this - you should feel respected, listened to, and be in an environment that feels safe and non-judgmental. You are by far the best judge of what works for you. Stay open, breathe a little, and take that first step on your journey.


  1. Thanks for this.
    I've considered therapy many times, and while I have yet to ever go (despite staring wistfully at the profiles of potential therapists), having this list will definitely help should I ever decide to take that leap.


  2. I recently decided to reboot my journey into seeking therapy (I had a few sessions back in 2006 and felt judged and lost, so I quit and have been too afraid to try again) and have been daunted by this task, so I started reading through your blog. This is something I've been meaning to do for a long time, actually. I'm loving it. Specifically, this entry is really helpful for easing some of the anxiety I'm feeling about finding a therapist I can be comfortable with and knowing what the signs even ARE that I might want to move on after the first session. Thank you so much. This entry actually made me a little excited about doing this.

  3. This is scary for me because my particular That One Thing is something that could theoretically if I got a therapist who couldn't handle it or sympathize trigger the "mandated reporter" stuff. (Short version: small kids, messy house. Some people are of the opinion that this is child abuse. Nobody who spends time around my kids regularly is of the opinion that they are maltreated in any way.)

    So I'm scared because being wrong about this would add incalculable stress when this is supposed to help me deal with stress. So now what?

  4. Anon - I can't speak for all therapists, but I would be shocked if a therapist made a child abuse report based on a messy house. In Oregon, therapists are not mandated reporters in a confidential therapy situation, just in a situation where they are NOT in confidential contact, i.e. something they learn in therapy is at their discretion, something they see in the grocery store is mandated for reporting. A therapist will weigh the good of the client and the children before reporting something that was learned in confidence, and I can't imagine they'd decide that busting you for a messy house was therapeutically indicated. Again, I can't diagnose and treat over the internet, and don't know what your therapist is like, but I'd be shocked.

    You might approach your therapist with a theoretical question first - what would you do if you learned ___?" That would ease your mind some, maybe.

  5. So much advice about finding a therapist echoes you're point number 3. Unfortunately I feel uncomfortable, unsafe and disconnected around everyone it's not very useful for me. Any other suggestions?

  6. Anon -

    I think when it's hard for you to connect with anyone, that's a great thing to tell a therapist during the first session. If your relationship radar is problematic, a good therapist will work with that, and building the relationship may end up being a long-term goal. You might be more comfortable working with someone more behaviorally-focused for starters, or with someone who will recognize that the warm fuzzy stuff needs to take time.

    Best of luck!

  7. What a great post for new clients! I am a Counselor In Residency in VA and just started a blog. I'm looking for some inspiration. Great!

  8. Nikki - thanks for the comment! Please feel free to share. Stick around, I'll have a whole book full of this stuff in the fall!

  9. Thanks for posting this - going to a first session is a terrifying thing, and knowing what to expect helps a lot. I always try to research what will happen, and I wish I had found this the last time I started therapy. Thank you.

  10. Kait - thanks so much for the comment. Let me know if you have any other questions - I need to do some posting! :)

  11. Thank you for this. I made my first therapy appointment a few days ago, and out of all of the "What to expect when you're expecting (therapy)" posts, this one has helped the most. I feel a lot more ready now. :-)

  12. You have an awesome blog and I just want to thank you for helping me accept the idea of therapy a little bit better. I had some traumatic incidences in my childhood with school-appointed counselors and therapists that have made it very hard for me to reach out and get the help I need. Your posts have alleviated some of my fears and concerns and I really appreciate you making them accessible.

  13. About to go for my first session tomorrow, odd that there are no comments after 2014 lol it helped me