Let’s say you have a list of therapist names. You know you need to call, but you keep putting it off. What are you supposed to say? What questions should you ask? And what is therapy like? If you have never been in therapy, or even if you have, therapy can seem like a foreign land where you have not yet learned the language or customs.
Index of topics:
The first interview
Limits to confidentiality
How much time do I get with my therapist?
What is it like to be in therapy?
What if things are not going well?
Is there anything I should avoid saying?
A unique relationship
How do I know when we are done?
The good news is that there’s nothing you have to ask. In fact, my clients rarely interview me. Still, I always hope that they will. If you can find out whether the therapist will be a good match for your needs during that first phone call, you may save yourself time and money.
As I mentioned in my previous post, the basics include telling your therapist about your primary symptoms, your reasons for pursuing therapy now, and also whether or not there is some urgency to your situation. The therapist will almost certainly ask you follow-up questions.
Before you pick up the phone, think about what may be important for you. Is it confidentiality? Credentials? Getting an idea of how long therapy will last? These are all valid questions. If you are considering paying “out of pocket” (not using insurance), consider what you are willing and able to pay. Think about how much your mental health is worth to you and how much you can afford over the course of several weeks or months; I always tell my clients that I don’t want them to pay me so much that it will mean they will have to cut their treatment short, but not all therapists have a sliding fee scale.
Other questions to consider include:
- What insurance do you take, if any?
- Do you have a sliding fee scale or any low-cost options?
- What kind of training do you have?
- What is your experience in helping people with my problem?
- How long can I expect treatment to last?
- How do you measure progress?
- How will you know when I’m done with treatment?
- How do feel about working with people who are gay/Christian/black/physically disabled/etc? (You want to be sure your therapist will make you feel welcomed, accepted, and supported, especially if you are feeling rejected from your community.)
This list is not exhaustive, by any means. Again, think about what is important to you.
The conversations that you have in the privacy of your therapist’s office are confidential. That means that he cannot talk about what you have said, or even that you are his client, to anyone. However, there are exceptions to this rule, which I’ll talk about in the next section. In most cases, you should have the opportunity to read and sign an Informed Consent form prior to your first session, which explains the therapist’s general policies, including limits to confidentiality.
There are two primary advantages to confidentiality. First, it allows you some privacy. Even more important, however, is that it gives you the freedom to open up completely to your therapist, sharing the most intimate, personal details of your life with him. This is rarely done in the first session and is most important if you are engaged in exploratory work, as opposed to something more task specific, such as stopping smoking. It is done over time, as your relationship with your therapist grows and you’ve come to feel safe and supported by him. Only by opening up and sharing things with him that you might not share with anyone else, is he able to really help you. For example, perhaps you smoke marijuana regularly. If you kept that from your therapist, not only might he misattribute your reported memory lapses to some other cause, but it would also mean that you couldn’t be completely forthcoming about the tension between you and your significant other, who, perhaps, disapproves of your habit. This would make it very difficult for your therapist to help you with the relationship problems that you report to him.
A good therapist cares about keeping your relationship confidential, so she will probably not strike up a conversation with you if you happen to see her in the mall or at a restaurant. In fact, your therapist may pretend she doesn’t even know you. Although it can be uncomfortable for you both, who likely have a close relationship, it is because your therapist is respecting your privacy and the importance of it that she behaves this way. Although it is your right to tell anyone you want that she is your therapist, she is ethically bound not to acknowledge the true nature of your relationship. You may, during therapy, discuss how you would like to handle the situation if, in fact, you happen to cross paths in public.
There are times when your therapist may talk about your case with others. Most commonly, therapists consult with other psychologists or meet with a supervisor. They talk with other professionals in order to give you the best care. Every professional involved in your case is required to maintain confidentiality and they avoid giving identifying information about you when possible. Because different therapists have different specialties and experiences, everyone, and especially you as the client, benefits from this practice.
If a therapist has reason to believe that you are in imminent danger of hurting yourself or someone else, he will need to get help for you. In most states there are also laws about reporting child abuse, elder abuse, and animal abuse. Also, if you pose a threat to someone else, in some states he may have to contact that person to whom you pose a threat. There are variations of this law in different states, so I cannot address law where you live. The best way to be informed is to read your therapist’s Informed Consent Form (he should provide you with one before the fist visit), ask for clarification if needed, and/or contact your state’s board of psychologist examiners; most, if not all, have their statutes and rules posted online, as well as information about how to report violations.
If you are using insurance, you are essentially giving your therapist permission to tell the insurance company about your diagnosis, progress, treatment plan, and so on. Also, if you are involved in the legal system, some lawyers may think your therapist could have juicy information about you that may help their case. Psychologists are obligated, however, to protect your privacy to the greatest extent that they legally can and may or may not have to comply with a subpoena. This is where it gets complicated, because of differences between situations, therapists, clients, attorneys, judges, state laws, professional ethics codes, and so on. In truth, it is difficult to predict what will happen because the details of each case differ.
Sessions will run 45 or 50 minutes, depending on your therapist’s preference. Some therapists, like me, reserve 80-90 minutes for the first session because she wants to have enough time to ask about the problem you are reporting and get your background information. “Intake” sessions, as they are called, are charged at a higher rate because of the extra time she spends with you.
Even though you don’t get a full 60 minutes with your therapist, you are likely getting more than an hour of her time. There are notes to write, other professionals to consult, phone calls with you, treatment plans to write, and for the majority of professionals, insurance companies to correspond with. Most therapists include, in their consent forms, a provision that says you may be billed for extra time spent on your case. Most will charge for any phone calls or consultations that exceed 10 minutes. Different professionals have different policies, so be clear about your therapist’s policy.
If your therapist didn’t have you complete your paperwork ahead of time, this is how you’ll probably spend the first part of your first session. Paperwork may include an Informed Consent form, a standard explanation of HIPAA and how it applies to therapy, perhaps a release of information form (so that your therapist can coordinate your care with other providers, if applicable), and sometimes psychological measures. Not only do such measures give your therapist a quick idea of how you are doing, but they can also give her a baseline against which she can later measure your progress.
While a therapist can give you a general idea of how long it typically takes to treat someone with your problem, there are always individual differences that may affect this timetable. Therapists typically take up to four sessions to complete their assessment of your particular case. Think of this time as a “trying on period” for the both of you. It takes this long to get your full history, learn about your symptoms and how they may change over time, learn about your strengths and weaknesses, and develop a good understanding of your problem. Only then can she realistically formulate a treatment plan. Although you may stop treatment at any time, the first four meetings should give you ample time to decide whether or not the therapist is right for you.
Some of my clients, especially during a first visit, say that they feel nervous, or that they’ve “never done this before.” It’s okay to feel nervous, but there’s really nothing you need to know about therapy before beginning; there is no “right way.” If you’re stumped for something to say, tell your therapist that. Each person has his or her own experience in therapy. It depends on you, it depends on the problem, and it depends on the therapist’s personality and style. The therapists’ theoretical orientation will also have a major impact on your experience. If your therapist has a psychodynamic approach, she will likely allow you to start talking first and will give you a lot of “space” to think, feel, and speak. A CBT therapist is more likely to be talkative and instructive. However, I am generalizing; you can have a very instructive, directive psychodynamic therapist and some CBT therapists are more talkative than others. Although therapists vary greatly on how warm they are, you should feel as though your therapist wants to help you.
Some people feel an instant connection with their therapist, but that’s not the norm. It usually takes time to get to know someone and establish a relationship that makes it feel safe to open up and share personal information.
Even if you interviewed a few therapists and thought you found the right one for you, you may find after a few sessions that a therapist is not the right fit for you. If you have concerns, a good therapist will want you to raise them. If the answers you get do not satisfy you, it is perfectly acceptable to move on. After the evaluation period (generally the first 3-4 sessions), your therapist may also decide that he is not the best therapist for you. For example, if he determines that you have Obsessive-Compulsive Disorder but has no experience treating it, he will likely refer you to someone else.
It’s nice to like your therapist, but it’s not enough. Therapists can be really warm, caring, supportive, and you can like them a lot…but can they help you? If you don’t think that you are making progress toward your goals, tell your therapist your concerns. This can feel scary to some clients, but I assure you, a good therapist will be happy that you said something. This gives him the opportunity to ask about your concerns, explain his treatment approach, and maybe make some changes; in fact, such conversations can often be very helpful to the therapeutic process. After talking about your concerns, you and your therapist may agree that perhaps you would be better served by going to someone else and he can give you referrals to other professionals. If you find the therapist is defensive or does not otherwise react well, then it’s a probably time to find a new therapist.
Not really. Talking about the day-to-day details of your life during every session will not be useful material for therapy. However, in the beginning of therapy, this is where you may dwell. Once you feel comfortable, you can move on to the bigger issues, patterns, and themes in your life. That makes for good therapy.
The therapist-client relationship is a unique one. You, as the client, reveal intimate details about your life, while you will probably learn little about your therapist. This makes sense, of course, because the work is about you. Once you end therapy, you may or may not need to talk with him or her again. Don’t try to friend your therapist on Facebook or provide reviews of their work on a public site; it would be a violation of your privacy and puts the therapist in the awkward position of telling you they cannot publish all the nice (or not-so-nice) things you said about her.
Your therapist in not your friend. This is not to say that your therapist does not care for you; on the contrary, it’s likely that she cares about you very much. So much, in fact, that she does everything she needs to maintain professional boundaries. Dual relationships (such as, if your therapist is also your next door neighbor or your hairdresser), interfere with the therapeutic process. Your therapist loses perspective and can no longer be helpful if she becomes too emotionally involved with you. A good therapist is able to strike a balance between caring for you and not becoming emotionally involved with you.
Sexual contact is NEVER permissable as part of therapy (ever watch the HBO show, “In Treatment?” That therapist had issues). Even if you end therapy, a personal relationship with him or her is potentially damaging to the work you have done and is frowned upon by professional organizations, such as the American Psychological Association. If you believe that your therapist has behaved inappropriately toward you, contact your state’s board of psychological examiners.
It is good to talk with your therapist regularly about your progress. This way, it’s not a surprise to either of you when he tells you it’s time to stop, or when you say you no longer think you need to come. If there are other issues that you would like to work on after resolving your current problem, be sure to let your therapist know.
Oftentimes your therapist will talk about relapse prevention with you and may see you a month or several months later to help make sure you are maintaining the gains made in therapy. This practice varies widely between therapists, however.
It can be difficult to stop seeing your therapist after you’ve developed a relationship with him. Some clients feel as though they owe their therapists a debt of gratitude and may bring him a gift. Although we as therapists need to be sensitive to why this is appropriate in many cultures, it is generally frowned upon in the psychology profession. And really, seeing a client progress to the point where he no longer needs treatment is a wonderful gift to a therapist.
My next post will be about Panic Disorder. Learn what it really is and how it can be successfully treated. Is there a topic you’re interested in reading about? Let me know!