How Therapy Works: What to Expect from your First Session

What happens in the therapy room has often been seen as a mystery. A large part of this is due to the fact that clinicians must uphold a level of confidentiality, so that patients feel safe in the knowledge that the content of their sessions remain private. Another reason why therapy can feel a bit mysterious is that there are different ways to practice psychotherapy i.e. some clinicians follow the psychodynamic tradition whilst others practice from a humanist perspective. In addition to this, there are prevailing myths around what happens in therapy that means that people often have a view of therapy that may or may not be misinformed. A typical one being the lying on the couch misconception. Whilst not completely false, the majority of clinicians do not practice in this way. It is no surprise then that people often feel unsure about what to expect from therapy, and indeed the very first session. In this blog post, I will share a few truisms of the therapeutic space, particularly as it pertains to that first session.

One of the reasons this article is so pertinent is that it can sometimes be a contributing barrier to people accessing therapy. If you have no idea what happens in the first session, it’s a bit like signing yourself up for a surprise where you have no idea whether it’s going to be pleasant, scary or a bit of both. As there are already so many barriers to people accessing therapy, it’s important to demystify what happens in the therapy room. In doing so, people can access the support that they need without unnecessary additional hurdles.

If you think about what the point of therapy is, it’s usually to help people (an individual, couple or family) navigate a particular issue. It could be anything from relationship difficulties, to dealing with life stressors, navigating a life transition or wanting to develop insight and self-awareness. Whatever the “presenting problem” may be, your therapist is going to need to understand it. And so one of the first things you can expect from the first session is that your therapist will ask you a lot of questions. And by a lot, I mean a lot! The official term for a first session is “assessment”. Other common terms include: intake session or initial consultation. They all generally mean the same thing. 

You may find that because there is so much to cover, your second and maybe even third session, are an extension of the first session. So the assessment isn’t strictly restricted to the first session. In fact, for many therapists, there is a belief that the assessment never really stops, as you are always learning about your patient. Indeed, even the patient may find that over the course of therapy they are learning about themselves too! So the assessment isn’t strictly a static task to be completed but rather a process that takes place over time. 

It’s probably important to stress here that not all therapists practice in the same way. We come from lots of different theoretical orientations, which might mean that you end up with a therapist that doesn’t ask many questions at all and they sit in silence, opening the floor for you to lead with whatever you please. However, for the most part, you will encounter in your first session, a therapist who is curious about: what the problem is, when it began, how it’s affecting you now and what you would like to be different by the end of your sessions. Though this sounds like a bit of a checklist, your first session may actually feel like you’re just having a chat. But rest assured, it isn’t just a chat. Instead, your therapist will be formulating an understanding of what is going on and how they might be able to help you. 

Many therapists also make use of something called outcome measures in their therapy. An outcome measure is a standardised questionnaire that will ask you questions about specific problems. It’s a useful way for your therapist to utilize a different medium to ascertain what you might be struggling with and how severe the problem is. It’s also useful as a baseline measure, meaning that over time they can track your progress and compare it with how you were doing at the very beginning of therapy. So don’t be surprised if you are given some outcome measures to fill out at your first appointment.

So that’s a little bit about the content of the session. However, there is also another important aspect of therapy which is: the process. Whilst sharing your story with a therapist, it’s not unusual to experience various emotions, either related to the problem or due to having someone witness you as you recount your experiences. Your therapist is trained to think not just about what you’re saying but how you say it and maybe also what you’re not saying. They will hold in mind what you might be avoiding, what themes are showing up in the stories you share, what feelings are associated with particular experiences, and how you might be feeling in your body as you talk about certain things. This is perhaps just one of the ways in which a therapy session might be different to talking to your friends and family about your problems. 

Now, whilst in your first session you don’t have to worry about much, as it’s your therapist who is there to do much of the heavy lifting. You do have two important jobs. The first being to be as honest as you can about whatever it is you’re bringing to the session. An assessment is only ever going to be useful if the therapist has all the information they need in order to be able to help you. And this might sound daunting as you’ve most likely never met your therapist before that first session. However, it remains a really important part of the process. The second important “job” that every patient should pay attention to in the first session is the “fit”. How you feel in the room with your therapist matters. It’s often cited as one of the most crucial factors that determines whether you’ll have good therapy outcomes! So you might want to view the assessment as a chance for the therapist to assess the problem and for you to assess the fit.  

In summary, the therapeutic boundaries that are intended to safeguard patients, have inadvertently meant that therapy is seen as a mysterious place. Coupled with the highly subjective nature of an individual’s healing process it then starts to make sense why it becomes difficult to fully demystify the process. But now that you know a little bit more about what to expect from that first session, below are a few reminders of what you shouldn’t expect to encounter:

1. Your therapist isn’t there to tell you what to do. In fact, therapy is really about empowering patients to make their own informed choices for their lives;
   
2. Your therapist will not push you to share more than you’re comfortable with sharing. You really do set the pace and your therapist will respect where you’re at in relation to self-disclosures;
   
3. Your therapist will not judge you for anything you share. Therapy has to be a safe space for it to work, and so your therapist will cultivate this with openness, curiosity and warmth. 

By Dr Shamarel Odusanya DClinPsy, AFHEA