Blog: Perspectives on mental health services

Becoming a more informed client and consumer

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The first therapy session: Knowing what to expect

If you’ve never met with a therapist before, you might feel quite in the dark as to what the first appointment would be like.  Will it be like meeting with a medical doctor?  If not, what’s the etiquette?  And when it comes to discussing your issues, where are you supposed to start? Alternatively, if you’ve had a bad therapy experience, you may feel unsure about what to expect from someone new.  Here, I share some thoughts on what you can anticipate in your first session, particularly from good therapy.  I also say more about evaluating the quality of the therapy and your fit with the therapist in a related post.

First, the therapist should make room for you to talk, particularly at the outset.  The beginning of the session—often much of the session—is more about understanding what’s on your mind than the therapist’s questions or agenda.  So this is already somewhat different than the standard doctor visit, which—apart from exchanging the usual pleasantries—typically focuses almost entirely on your symptoms and complaints.  But it also makes sense because, while the therapist wants to understand your symptoms, he or she needs to understand them in the context of who you are, how you see them and how you experience them.  Some therapists will go more quickly into questions than others but, in general, the first session should not feel like a job interview.

Of course, the idea that the therapist will leave room for you to talk can also be intimidating, particularly if you’re not sure how to describe your troubles.  Rest assured that this is very common and a good therapist will be both patient and helpful.  Also, you should feel free to start wherever you want.  There are no rules about what’s most important or most relevant.  In fact, where you choose to start actually helps the therapist understand the nature of your difficulties and how you think about them, so it’s more helpful than trying to start where you think he or she might prefer.  Also, don’t feel pressure to explain everything in the first session, which probably isn’t possible anyway.  It’s sensible to try to express what you’re finding most upsetting or most troubling, but sometimes even this can be difficult to articulate, particularly at the beginning.

Keep in mind that you don’t have to talk about anything that’s too uncomfortable or that you’re not ready to talk about.  Of course, this means the therapist won’t have the whole picture, and this may limit our mutual understanding of your struggles.  That said, therapists don’t expect you to be able to—or even want to—tell us everything upfront.  Also, it’s not our job to force you to talk about anything, and it’s perfectly acceptable to say you’re not ready to talk about something yet.

When the therapist does ask questions they shouldn’t seem like a shift into what he or she wants to talk about.  This could actually feel quite different from talking to friends or loved ones, who might be eager to jump in with advice or questions that align more with their personal interests than yours.  Also, though, I don’t mean that your therapist won’t zero in on key issues; indeed, good therapists will.  But, hopefully, this zeroing in will feel more on target, like bringing your personal concerns into sharper focus.  Ideally, talking to your therapist will feel like he or she is curious about what you think and is trying to fully understand.  The one time the therapist may shift into guiding the conversation more explicitly is if you’re engaged in potentially dangerous or harmful behaviors.  This might prompt the therapist to ask a number of direct questions, but these are designed to clarify your degree of risk, to ensure that you’re safe, and to make sure he or she provides the immediate help that you need.

Your therapist should not judge, criticize or scold you.  Our job is to understand and help, not to critique, and not to sit in judgment of your mental health.  Many new therapy clients understandably worry about what their therapist will think about them.  After all, you may be sharing thoughts, feelings, hopes and fears that you’ve never shared with anyone before.  Furthermore, you may be trying to talk about ideas or behaviors that you feel quite guilty about or ashamed of.  But many clients are surprised to learn that their therapist actually judges them less harshly than they judge themselves.  Even in the case of problematic or harmful behavior, our role—in addition to ensuring your safety—is to understand why you’re doing it or why you can’t stop, not to conclude you’re morally or emotionally deficient.  You wouldn’t be coming to talk to us if you didn’t want to stop.

In order to facilitate this conversation, the therapist should be interested, curious, and thoughtful.  This starts to get into evaluating the quality of the therapy, which I cover in more detail here, but it is nevertheless worth emphasizing again:  your first therapy session is not an interview or an interrogation, but an attempt to understand you and where you’re coming from.  This does not mean that it’s always a warm and fuzzy, touchy-feely conversation, and when the therapist does make comments or observations, he or she should be honest, straightforward and direct.  But at this point, such observations are likely to be more tentative: even if the therapist has noticed something significant, he or she should seem more interested in seeing what you think about it than in trying to pigeonhole you.

As I noted, none of this means it’s easy to talk about these things, or even to come in in the first place.  But I hope this does clarify what you can expect and—if you decide to try therapy—helps you to think about how to approach your first session constructively.