Establishing collaborative goals for therapy is one of the most important things you can do in the first session. Paradoxically, this is often where I hit a big roadblock in the first conversation. People will spend a lot of time talking about what’s been going wrong, what’s bothering them, symptoms, failed solutions, etc. Then when I ask them what they hope to get out of therapy, they look at me like I just asked them why they put on pants before they came to see me.
I get it, it’s a weird question. For most people it’s obvious – they’re suffering, they’re in pain, and they just want to feel better. If I’m feeling particularly playful I’ll ask my next difficult question: “Why do you want to feel better?” One of my all time favorite psychology writers, Victor Frankl, would say it even more challengingly – “Why do you not commit suicide?”
I’m too scared to ask that way. Hell, I don’t even like putting that question on a website without linking to resources for suicide. Still, it’s a good question.
It’s all about you
We ask all of these questions to get at your goals for therapy, which should be related to your goals for life. Most people in their first session talk about external stressors – “My life sucks because…” work, family, health, money, whatever. I’m just a therapist, there is nothing I can do about those things. I think that some people come in and expect that just by talking about these problems, they’ll start to feel better about them. This is true, but you can talk about those problems with anyone – your friends, your barber, strangers on the internet, whatever. That’s not really where therapy adds its value.
Other therapists will argue about this, but I believe that therapy is about change – changing your attitude, changing your behavior, changing your habits, changing your circumstances, etc. The thing is, I don’t know what it is in your life that you want to change. You have to tell me that. By asking why you haven’t killed yourself, Frankl is really asking what you’re continuing to live for. If your life is so miserable, what is so important that you are willing to continue suffering for? I can’t tell you what that thing is – it might be family, an unfulfilled life goal, vengeance, whatever it is, it has to be from you.
It’s a lot to expect a therapy client to just list what is and isn’t working in their life off the top of their head the first time they meet me. That’s why it’s helpful for you to think about them ahead of time. So here are a few questions to ask yourself ahead of time, so you can be prepared when your therapist asks them to you.
The Magic Wand Question
“If I could wave a magic wand and take away all of your mental health issues, how would your life be different?” This is a good question to get at the real impact of your mental illness – what is it keeping you from doing or accomplishing? It also can help you communicate some of your overall life goals. Picture your life without anxiety or depression or alcohol or whatever it is you think the problem is. Do you have a relationship? What is your job? What are you spending your time doing?
As weird as it is to ask this for a question about magic wands, be realistic. Taking away your depression won’t instantly make you a rock star. Taking away your anxiety doesn’t mean that you also magically know how to talk to the opposite sex. You’re still you, but what does the you without mental illness look like?
What do you want to change?
It can be helpful to do a pretty thorough life inventory before you come to see a therapist. More and more, therapists are being trained to think about Total Health, which is to say incorporating all the different dimensions of life (physical, mental, spiritual, occupational, recreational, etc.) into their conceptualization of what is going on with you. Some of those dimensions you might be doing pretty well on. Some of them you might be struggling.
I like how the VA has executed this: they’ve basically come up with 8 Domains that can affect your overall wellbeing: physical exercise, physical environment, diet, sleep, personal development, relationships, spirituality, and mental health. Your therapist can be the point person for all of these. Go ahead and take a look at their worksheet and do a little mini-inventory for yourself. This can help you think a little more globally about your quality of life.
What are your strengths?
This kind of goes back to Frankl’s question about what’s keeping you in your life. What are the parts that are going well? Most people that come into therapy aren’t looking for a total lifestyle overhaul, so we as therapists want to know the areas that are working pretty well on their own.
Just as important, we want to get a sense of the resources that we (that is to say, you and your therapist, who will be working as a team on this) have at your disposal. Think about the ways that you have coped before and what’s worked, in addition to what hasn’t worked. Think about the people that you have around you who would be available or willing to help you if you asked. What skills do you have? What interests? What makes you the unique, beautiful precious individual that you are?
Try not to let your mental illness talk you out of this one. Your self-esteem may be in the toilet as part of everything that’s going on, so try to go easy on yourself. Have a low bar for what might be considered a strength. Do you have a sense of humor? That’s a strength. Are you still on speaking terms with your family? That’s a strength. Can you list the names of all 150 original Pokemon? That’s a strength.
What are the bitter pills that you have to swallow?
Complaining to your therapist about things that you have absolutely no control over is not a good use of your time or your therapist’s time, but still this seems to be what most people want to get out of therapy. That doesn’t mean that therapy doesn’t have any inroads to make in this area; really, the process is about acceptance.
Earlier I mentioned that I think therapy is all about change. Many therapists would say that it is equally about acceptance. One of the central dialects in dialectical behavioral therapy is between acceptance and change – accepting yourself for who you are while at the same time trying to change. I would argue that beginning to accept something that you had previously tried to reject or deny or avoid is a change, and accepting reality as it is can be one of the central foci of your therapy. So whether you’re accepting your own mortality, or the loss of a loved one, or terrible things from your past – think about the things that are renting space in your head, so you can begin coming to terms with coming to terms with them.