What Should I Expect in the First Few Therapy Sessions?

While each psychologist and therapist is unique and therefore approaches the therapy through a slightly different lens, there are certain commonalities that exist. Knowing what to expect when you first start therapy can make the process feel a little less daunting.

What follows is a brief outline of what you might expect during the beginning phase of therapy/counseling. 

Presenting issue(s): focusing on the struggles and uncertainty that bring you to therapy

The session will center around the emotional struggles that motivated you to seek therapy. In psychology this is called “the presenting problem.”

“Tell me about what’s going on for you”; “How can I be of help to you?”; or “Why do you think you need counseling/therapy?” are examples of questions a psychologist or therapist might ask to help start a dialogue about you and your life. 

You are in charge of what and how much you share. The psychologist/therapist should convey that you are in control of what is and is not shared. Some of us need more time to get to know a therapist in order to talk about very painful and personal experiences. There is no right or wrong way to do this. It may take weeks, months and, in some cases, years.

You may need to feel a deep level of trust with your therapist before discussing the most vulnerable parts of yourself. Some of us carry pain and secrets that have never been voiced to another.

After the first meeting, you should come away with a sense that the therapist is genuinely interested in and is working to understand what is going on for you. 

History of the presenting issue

Have your emotional struggles occurred before?

If symptoms of depression are, for example, the reason you’re seeking therapy, it will be important to discuss how long you’ve been struggling and whether there were other times in your life when you’ve battled depression. For some of us, depression is episodic and doesn’t return; for others, it’s an unwanted, repeat visitor.

Exploring the recurring patterns of a particular struggle can help shed light on the events (and the meaning given to these events) that may trigger certain emotional difficulties. This process gives clearer shape to the contours of your struggles, ultimately giving you a means for traction out of them.

Goals of therapy

A focus of your current struggles should naturally lead to a discussion of the goals you’d like to reach in therapy.

These can be symptom-focused goals, such as: You want to feel less depressed and more motivated and focused; You want to feel less guilt and self-torment about something that has occurred in your life; You want to be able to drive on highways without having anxiety attacks; You want greater control over certain addictive behaviors (for instance, to stop drinking or using drugs; gambling; watching pornography).

Or your goals may center around more general self-improvement objectives. These might include:  Understanding and changing certain self-sabotaging patterns; You want to shed light on the  perpetual “stuckness” you feel in your life; There is a desire to understand how the dynamics of your past continue to shape you; Your romantic relationships end in familiar ways despite your best efforts.

From the outset of therapy, you might be clear about the particular goals that are meaningful to you. Or, you may need to work with your therapist to clarify the direction in which you want to travel. In either case, establishing the goals you’d like to achieve in therapy should be a collaborative effort between you and your therapist.

These goals should reflect where you are in your life and where you’d like to be.

Unrealistic goals can lead to a frustrating therapy experience

Therapy goals should be realistic. For instance, the goal to “always be happy” may not be realistic because it presupposes that you shouldn’t feel any negative emotions like sadness, grief or anger (even when these feelings are appropriate).

When discussing goals, your psychologist/therapist shouldn’t over-promise what therapy can offer. Yes, therapy can be a very powerful, transformative experience; and it can be a frustrating one.

A note about the happiness goal: When clients say they want therapy to make them happy,  I explore what they imagine a happy life would look like — and often what emerges is that they want their pain to stop. This might be the pain that is inherent to life’s journey, the pain of a failed marriage/relationship, or the suffering caused by traumatic events.

Psychotherapy/counseling can be restorative. The therapy process helps us work through (and walk through) what freezes us emotionally while also helping to restore our capacity for richer self-experiences — experiences that may include greater happiness and joy.

Looking at the big picture of your life (expanding the lens)

While it was likely your current relationship or emotional difficulties that brought you into therapy, the essence of who you are is bigger and more expansive than these struggles. When consumed by pain, it may feel like nothing but pain exists. Fear and emotional pain does that, it narrows our vision until we are slowly convinced nothing else exists. 

Your struggles unfold within the larger context of your life — your therapist will ask questions to get a fuller and more complete picture of who you are: What are your values, interests, passions and dreams? What brings meaning to your life? Where do you achieve “flow”? What keeps you up at night?

In short, who are you beyond the presenting problem that brings you to therapy? 

Developmental history

Some therapists like to structure the early sessions by taking a thorough history of your life (a history of your childhood, adolescence, family of origin dynamics, peer relationships, school and dating experiences). They may use part or an entire session or two focusing on your history.

The reason for history-taking?

Understanding where we came from can help you get to where you want to go.   

Some therapists take a less structured approach to history-taking. For example, they may ask questions about your childhood when it feels relevant to something that is presently occurring in your life (or in the therapy session). With this less structured approach, the history of your life will be asked about over a series of sessions rather than a designated time-frame.

And, of course, you should have input about which approach (structured or unstructured history taking) works best for you.

Is this the right therapist for me?

After the first or second session, you and your therapist should have a discussion about whether it makes sense to work together. If your therapist doesn’t feel like s/he can be helpful to you, then this should be clearly stated along with the reasons why s/he feels this way.

After a couple of sessions with your psychologist or therapist, you should start to get a sense of how s/he works. If s/he feels like the right therapist for you, it’s probably because you’re feeling listened to and understood. You may also feel accepted and challenged — challenged in a positive way, toward self-growth.

Remember, you should be assessing your therapist in order to figure out if s/he is the right person for you. I encourage new clients to ask me questions if this will help them in this assessment process. Sometimes it will feel like a good fit right away and at other times, it may take some time to make this determination. Either way, you took a courageous step in seeking help. 

Until next time,

Dr. Rich Nicastro