So I made my first appointment…now what?
You finally did it. You spent months contemplating whether or not you feel ready for this. After spending hours scrolling through Psychology Today and talking to a few different therapists on the phone, you found someone you think you may work well with. You're proud of yourself for making this great stride, but also wondering if you will regret it.
It may seem cliché, but it's true in that the first step is always the hardest. Sending that first email or making that first call to say "I think I need help," can be horrifying. If you have been wrestling with the idea of starting therapy for months, even knowing that you've needed it, but struggling to make the initial call, please give yourself grace. Starting therapy can feel challenging, intimidating, overwhelming, and scary. If you're feeling these things, know that these feelings are very normal.
When you are able to take that leap of faith and book your first appointment, pat yourself on the back! Congratulations! You made it past the hardest part of the process . Maybe you recognize that this is a big step for you and you are proud, and yet you feel uneasy, because this is so new. (Again, normal feelings.) Once again I would encourage you to give yourself grace and validate that discomfort.
Truthfully, the uneasiness and the unknown about what happens in therapy is one of the biggest reasons why people are hesitant to reach out. What I have found is that the more I am honest about the process of therapy, the more comfortable clients, and prospective clients feel. You are allowed to ask questions. You are allowed to have reservations and hesitations. And, yes, PLEASE ask for a consult before scheduling an appointment.
With that, I wanted to provide a little insight into what happens in a first therapy appointment. Please keep in mind that every therapist does things differently, so my approach with clients may be different than your therapist's approach with you. This does not mean that either of us are doing anything wrong. Every therapist is different, and the best therapist for one person may be the worst for someone else. That's okay! Keep this in mind as I do my best to give a blanket explanation of what happens in the beginning of therapy.
The Initial Intake
The purpose of the intake is, in simple terms, for the therapist to get to know you. Keep in mind that your therapist wants to learn about you, your strengths, your struggles, your job, your family, and your relationships. Anything that's important to you is important to your therapist. Because of this, yes, your therapist may ask you a lot of questions and take a lot of notes, either hand written or typed. They also may give you assessments that measure anxiety or depression levels. At this point, your therapist is just gathering information, in the same way that a potential employer would conduct an interview.
In an intake, your therapist will also go logistic things like payment, confidentiality, informed consent, and whether else may be important. After that, they will probably ask about psychiatric and medical history. Typically, it is important to know if a client has been in therapy before or has ever been treated for a mental health condition. Even if this was 10 years ago, it's still an important thing to talk about. We therapists ask about trauma histories, mental illnesses in the family, development/academic history, vocational history, eating habits, sleep hygiene, drug use, and overall mood. If we feel it is necessary based on current information given, we will ask about suicidal history or a history of self harm.
Remember, everything matters. If your therapist is asking something, it's likely relevant- even if you don't understand why. But, here's the thing: Therapists do not expect clients to spill their deepest darkest secrets during the first session. In fact, therapists expect broad answers and realize that there will be some things you do not want to answer. It's okay to choose not to answer. If there's something that you feel uncomfortable disclosing, you don't have to. This is because YOU, the client, are in charge. A good therapist will respect your decision to not touch on a topic and usually can tell when an area is triggering, so they may not even go to that area to begin with.
If you're in your intake and find yourself uncomfortable answering so many questions, or it feels like you're being bombarded, I encourage you to talk to your therapist about it. We understand that this is a weird, unique process. And let's face it, when you first meet us, we're nothing but random strangers! We wouldn't expect you to confess your whole life's trauma to someone you just met, and a therapist, although a trained clinician, is still technically in this category. This is why I'm a huge believer in the relationship between a client and therapist. Therapy is relational and collaborative in nature. Without trust, deep therapeutic work is just not possible, and trust does not happen in one session.
If you see a therapist outside of your insurance, therapists do not legally have to diagnose on paper. However, a good therapist is always assessing, and may be noticing symptoms of a particular diagnosis. They will often use this to guide treatment, and nothing more. But, please keep in mind that therapists are trained in assessment and diagnosing. The diagnosis may not be used as a label, but symptoms give us important information to use.
I do have to be honest. Here's where the anxiety can come in. Your therapist is assessing you throughout the entire session. This is not to judge you, or to be creepy, but it's kind of within our job description! We have to assess in order to know how to help you. Your therapist will pay attention to your affect (emotions and mood), your body language, your tone, your facial expressions, your volume, your eye contact, your thought process, and more. I am honest about these things not to scare you, but to prepare you. If you have no idea what your therapist is looking for or what they're jotting down, that can bring anxiety that leads to shutting down. Especially during the intake, it is important for you to feel comfortable and relaxed. (The uncomfortable sessions will come AFTER a relationship is formed!) All in all, if you are noticing deep feelings of discomfort or anything related, it is very important you bring this up in session. This actually tells us a lot. And remember, we are human too and get that it's scary.
What about a diagnosis??
Ugh. Here's another thing I have to be honest about. The elephant in the room, which transfers to a diagnostic code on a therapy invoice. So many clients enter therapy asking if they will be diagnosed, and the answer is both yes AND no.
When you are paying with insurance, insurance will not accept the bill from the provider unless there's a diagnosis attached. And, some insurances don't accept certain diagnoses as reasons for someone to "Be in therapy." (I guess that's good in some ways, cause otherwise I'd be diagnosing all my fellow coffee drinkers with caffeine addiction!! It is in the DSM- look it up if you don't believe me!) These insurance "rules" are not something that I, or most therapists agree with, but we unfortunately do have to comply.
So based on our initial assessment, we will put a diagnosis that seems most fitting. For example, if you reported any sort of traumatic event but don't meet the criteria for PTSD (or we don't see it at the time of the assessment), we may diagnosis you with Unspecified Trauma Disorder. If you are starting a new job and experiencing normal amounts of worry, we may put Unspecified Anxiety Disorder. Likewise, there are Unspecified Disorders in the DSM that we use commonly for this reason. We recognize that not all people coming into therapy have these big diagnoses. So, we use our best judgment. These diagnoses are really for treatment planning purposes, but most therapists don't put a heavy emphasis on them unless the diagnosis is something obvious and more severe.
Some therapists are more diagnostic focus than others. Personally, I don't like diagnosing. It can create unnecessary feelings of shame and stigma. Clients will often ask me about their diagnosis, and I will talk it through with them and answer them honestly. You, as the client, are allowed to ask about your diagnosis and if you don't think it's right, then it's okay to explore that. Let me let you in on a little secret: Therapists get diagnoses wrong sometimes. It can feel impossible to give an accurate diagnosis after meeting with a client for only an hour, especially knowing that client’s often don’t disclose a lot during the first meeting. Diagnoses often change upon further assessment. A therapist may not even see symptoms of a specific diagnosis until the 4th appointment. This is why most of us hate diagnosing, because mental health is so subjective. There's no clear cut version of Major Depressive Disorder or Panic Disorder. It's frustrating- for both therapists and clients.
In conclusion, I will never ask "What's the problem?" This is because I don't believe that people come with problems needing to be solved, but rather wounds that they want someone to look at. Because therapy is medical care, it can be looked at in a similar way. If you go to the dentist with a tooth ache, they will poke around until they find the sore spot. When they do, they may say "Aha, there's your source of pain! You have a cavity!" Therapists do this type of work, in a more objective way. We look around, notice your sore spots, and identify the source of pain. Maybe it's a small little cavity that needs a filling. Or maybe it's an abscess that needs a root canal. Whatever it is, we want to help identify, and then alleviate that pain. We care about you, so thank you for trusting us enough to look around your brain.
