Blog: Perspectives on mental health services

Becoming a more informed client and consumer

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The first therapy session: Evaluating quality and fit

In your first meeting, the therapist is trying to understand your issues, but you’re also trying to get a sense of the quality of the therapy and whether or not you and the therapist are a good match.  If you’ve been in therapy before, you might have a sense of what you’re looking for.  Even so, how do you size up a new therapist?  And if you’ve never been in therapy before, it might be hard to know what you’re looking for, and it might be hard to figure out if this therapist is any better or worse than any other.  In this post, I’ll talk about the questions you can ask, but I’ll say even more about what you can look for in the therapist’s attitude, comments and behavior.  I also discuss the basics of what to expect in your first session in a related post.

Some psychologists emphasize asking specific questions about the therapist’s approach in the first session, but I’m skeptical about how helpful this is in practice.  For one thing, there are hundreds of therapy approaches and the research is constantly evolving, so it’s unrealistic to expect most consumers to be sufficiently informed to make sound judgments about specific approaches.  Also, many consumers are struggling to understand their own condition at the beginning of therapy, and many present with aspects of multiple conditions, so aligning specific techniques with specific symptom clusters can be a challenge.  Finally, many therapists nowadays draw on a variety of theories and techniques, so the honest answer may be “eclectic” or “integrative,” which probably doesn’t help much.  Questions about approach also don’t clarify the quality of the therapy, or whether the therapist’s temperament and style are a good fit for your current needs.

I do believe that such questions can be useful—particularly if you have a clear sense of your symptoms and are looking for a specific remedy—but they’re probably not the most meaningful starting point for most consumers.  Luckily, there are a variety of additional factors you can explore to get a clearer sense of whether the therapist and his or her approach will be a good fit.  First, broader questions about the therapist’s experience and expertise may be illuminating, and you can certainly ask if the therapist has experience with the kind of issues you’re struggling with.  You can also ask about where the therapist went to school or other aspects of their training that may be relevant.

In addition to these questions, though, I believe it may be even more valuable to know how to tune in to and evaluate the therapist’s approach during the session.  Initial sessions provide a first-hand sample of therapists’ “model of mind:” you have a chance to see live examples how they think about human nature and how they approach their job.  What do they ask about, and what do they appear interested in?  Do they focus on your thoughts, your past, or your relationships?  How do they talk to you?  You can also learn about your therapist’s interpersonal style.  Are they warm and nurturing?  Or are they a little tougher and more no-nonsense?  Does this style feel like a good fit?

It’s often wise to get a head start on this by thinking through what you’re looking for in advance, not just in terms of approach, but in terms of temperament, personality and style.  Do you think you need someone who is more nurturing, or someone who will be able to confront and challenge you?  Do you have issues in your past that you feel it’s important to explore, or are you more concerned about the here and now?  Do you want someone who will listen patiently, or someone who is more ready to jump in with questions?  Keep in mind that most experienced therapists will know when to shift their stance depending on the circumstances—for example, being supportive and comforting but also knowing when it’s important to be more challenging.  Even so, the first session can give you a good sense of their preferred style.

There are also some hallmarks of good therapy in general that you can glean from the therapist’s attitude and behavior during the first session.  For example, all good therapists are likely to come across as interested, curious, and thoughtful, as well as honest, straightforward and direct.  They should not only be interested in your symptoms—such as your mood, behavior or sleep patterns—but also in your subjective experience.  For instance, if you’re depressed, the therapist should be interested in both how depressed you are and in how you are depressed.  In other words, how do you experience the depression?  What are your personal thoughts, feelings and perceptions?  How do these mesh with your personality and life story?  Good therapists tend to be interested in both your symptoms and the nature of your distress, and will strive to understand these in the context of who you are as a person and the challenges you’re currently facing.  Obviously, not all of this will be sorted out in the first session, but you can nevertheless get a sense of whether the therapist is thinking in this direction.

Finally, keep in mind that you’re allowed to shop around.  Going to the first therapy session is not a commitment to continue with this particular therapist.  Indeed, sometimes clients prefer to attend two or three sessions before deciding to continue.  Good therapists understand this and will not take offense.  Like you, we want the therapy arrangement to feel like a good fit.  We may end up talking about uncomfortable topics during the course of your therapy, but we want you to be comfortable with who we are and how we’re trying to help.  And the first session is an opportunity for you to make your own assessment of this.