What Your Therapist Will Say on Your First Session

Prepare for Information Overload

There are a few things that we’re legally obligated to say in the first therapy session, and there are a few things that are helpful for you to know in the very first session. Many therapists try to combine all of these into one mini-lecture at the beginning of the session to try to get them all out of the way. Meanwhile, you’re there mentally rehearsing how you’re going to bare your soul to a stranger for the first time, when your attention is jerked back to what this guy is saying when words like “suicide” and “involuntary hospitalization” start coming up.

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“I feel I missed an important detail.”

I hate that good practice requires us to provide the psychotherapy equivalent of an End User License Agreement in the first 10 minutes of your first session. I understand the need for it, but before you click “Accept,” I want to make sure you really understand what is I’m talking about. So here are a few basic points about what the hell it is I’m talking about during that first therapy spiel.

Informed Consent

According to that bastion of ethical practice (see link for sarcasm), the American Psychological Association: “When obtaining informed consent to therapy … psychologists inform clients/patients as early as is feasible in the therapeutic relationship about the nature and anticipated course of therapy, fees, involvement of third parties, and limits of confidentiality and provide sufficient opportunity for the client/patient to ask questions and receive answers.”

My skepticism about the APA aside, this is a great rule. Basically it says that before any treating professional does anything to you, you have to consent to it first. This is true of medical doctors, psychiatrists, occupational therapists, chiropractors, whatever. And this is procedure specific – your psychiatrist can’t just up and decide he wants to switch you from antidepressant medications to Electroconvulsive Therapy without your permission. How formal or informal this consent process is can vary – for more minor procedures, a doctor might just ask “Is it ok if I…” and then write down if you said yes or no. More intensive or specialty treatments, and because psychotherapy occurs across several sessions it’s generally considered in that category, may require a signed form.

In order for your consent to really be “informed,” you have to know a few things. One is the risks of treatment. Psychotherapy is generally pretty low risk to your overall health and wellbeing – I don’t think a therapist has ever left a scalpel inside a patient. It is fair for you to expect therapy to cause you some discomfort, or at least put you outside of your comfort zone. Some forms of therapy are more intensive in this way than others. At the Center for Anxiety and Related Disorders at Boston University, they say: “you must be willing to experience considerable anxiety and panic symptoms during the course of treatment. This is essential to your recovery. If you are not willing to do that, this treatment will not work for you.” Other treatment programs will not be so intense, so this is where it’s important to do your research and shop around.

Russ Jani
“Are you sure this is the only way to treat my fear of being strapped to men with red sweaters?”

Another important part of informed consent is listing the alternatives to treatment. If you’re getting a very specific type of treatment, like Prolonged Exposure or Dialectical Behavioral Therapy, your therapist might discuss the advantages and disadvantages of these treatments compared to “traditional psychotherapy” or CBT. If you’re getting less specialized treatment, your therapist might talk about alternatives like psychiatry, group therapy, or self-help options. I wouldn’t necessarily expect the therapist to be totally even-handed either; they know a lot more about the treatment that they’re offering than they do about the alternatives, and many therapists get paid per client. At the same time, no therapist wants an unsuccessful client, so if you’re not a good candidate for their treatment they’ll let you know.

Limits of Confidentiality

The therapeutic relationship is built on trust. You should feel certain that you can tell your therapist things that you wouldn’t tell your parents or your significant other – those dark secrets that have been eating away at you. Confidentiality means exactly that – your therapist is legally restricted from telling anyone about anything you say… with some exceptions.

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This is not one of those exceptions.
  1. Abuse or Neglect of a Protected Class. Children, elderly or disabled, if you give your therapist any information about abuse or neglect of anyone in those classes, they are legally required to report it to the appropriate agency. It doesn’t even have to be your kids, etc. If you tell your therapist that your next door neighbor beats the shit out of his kids every night, your therapist is legally required to call child services on that guy.
  2. Danger to self or others. If your therapist thinks you are at imminent risk of making a suicide or serious self-harm attempt, or killing or seriously  harming someone else, they  have to try to prevent that. This might include an involuntary hospitalization, or calling your potential victim’s local police department. Now, this doesn’t mean that your therapist will lock you up if you tell them that you woke up this morning with the thought that you’d be better off dead, or that you wanted to shoot the guy who cut you off in traffic yesterday. What it does mean is that if you tell us things like that, we’ll probably ask for more details. What we’re looking for is whether or not you might act on these ideas. We’re not alarmists – we know that suicidal thoughts are extremely common, and most are vague and transitory. We also know that some of them aren’t, and part of our job is to keep you alive long enough for therapy to start to work. If this sounds worrying to you, here’s another article that goes into a lot more detail about suicidal ideation and therapy.
  3. With your permission. If you give us permission to talk to someone, we can talk to that person, but only about the things you authorize us to talk about. Most commonly, you need to give us permission to communicate with your health insurance company so that we can demonstrate that we are providing good services and making progress. We might also ask for permission to talk to your Primary Care doctor. Some people will need us to talk to their employer or parole officer. Again, unless you specifically ask us to, we won’t be telling them exactly what happens in session. We’ll just be giving them the need-to-know information we have to.
  4. Court orders. If we get subpoenaed, or if there is a warrant, we have to obey that court order. This can get sticky in divorce situations, where custody disputes may call into question one parent’s ability to cope with the demands of parenthood. What I generally tell people in this situation is that it’s probably better to show that you are getting some treatment for these mental health issues. Here’s a little more detail about divorce proceedings and medical records.

That’s pretty much it. We don’t have to disclose any previous crimes, or your plans to commit future non-violent crimes.

grandma christmas tree
Your secret’s safe with me.

Expectations of Therapy

I have found this over and over again – if I’m the one doing most of the work in therapy, it’s not going to go well. Therapy is great – it’s supportive, accessible, warm, challenging, fascinating, even fun! It’s also only one hour per week, sometimes even less. What you’re doing the other 167 hours is going to do a lot more for your progress than that one hour when you’re in the office.

Most good therapists assign homework. This might be readings, worksheets, practicing new skills, independent research, brainstorming, meditations, exercise – it could be anything. They might be a little uncomfortable, or awkward, or weird. If it seems like something that you wouldn’t normally do, or something that goes against your grain, that’s probably the idea. If your normal habits and solutions were working, you wouldn’t need therapy.

This isn’t to say that you should just act on blind faith. There should be a reason behind everything in therapy, both the in-session work and the between-session work. If you don’t know what that reason is, ask. Therapists tend to get a little too enculturated into the mental health field and we forget that not everyone knows the biological and behavioral causes of illness and wellness. The reason behind an activity might seem obvious to us, but you might have no idea.

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“I mean, if my therapist said to…”

So another expectation of therapy is honesty. It always slightly blows my mind when my clients lie to me, whether it’s about their drug use, or whether they completed homework assignments, or if they slept with an ex. This is a service for you, where you set the goals. Pretending to do your homework when you actually didn’t benefits neither of us. I do get it: nobody wants to disappoint someone they care about, even their therapist. I also think some clients expect us to be mind readers or human lie detectors, but I’m afraid I’m no better at spotting a liar than any other schmuck off the street. So it’s on you to tell us the truth. That way we can help figure out what went wrong and how to fix it.

Finally, and perhaps most importantly, we expect you to show up. Cancellations are one thing, but there are few things more frustrating to a therapist than a no-show. We put in all of our prep work, block off the time, get all dressed up, and you stand us up like the protagonist in the 2nd act of an 80s teen movie. Again, I get it. I get the little whispers that depression and anxiety put into your brain – you’re not worth it, someone else deserves it more, it’s too scary, it’s too hard. Don’t believe them. I want you there. I want to help you fix this.

Juan Pablo Arenas
I may or may not be gazing wistfully out a window.

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