A Beginner's Guide To Starting Therapy
Experts share their tips on finding the therapist who's right for you.
1. How do you even find a therapist?
It's absurd how daunting and confusing this first stage can seem, especially when it's likely that part of the reason you're seeking therapy is that you're feeling overwhelmed. (And if, after reading all of this, you still feel that this first step is just too difficult, know that you can and should reach out to loved ones to help you make these calls!) But there are ways to make this imperfect process a bit easier.
"It's very difficult, as a patient and customer, because you don't know very much going into it," says Dr. Jacques Barber, dean and professor of the Derner Institute of Advanced Psychological Studies at Adelphi University. "If we had a better rating system for therapists it would be easier, but we don't. A lot of the time we go by reputation, and that helps. You can check listings of therapists at PsychologyToday.com, which is pretty good. We can ask our friends, but sometimes they can't always tell us the truth, as they might not want us to see the same therapist."
Many insurance plans provide databases where you can search by location, method of therapy, and specialty. Susan Lindau, LCSW and University of Southern California professor, recommends getting referrals from other health providers, especially if you're looking for a specific area of expertise. "If a client is seeking specialized services, s/he will ask for a specific type of support from another therapist," she says. "My referrals often come from a previous therapist or psychiatrist or a treatment facility."
The best thing to keep in mind is that it's often a matter of trial and error: You might talk to a few different therapists before you land on the right one, and that's OK.
2. What are the different types of therapy?
Keep in mind that not all therapies are alike, and knowing a little about different therapists' styles and specialties can help you narrow your list.
"There are two big categories of treatment and, within each, several styles," says Lindau. "[One is] psychoanalytical practice, which is seen as an anachronism in this health care economy — it frequently continues for years, exploring events that occurred in the patient's childhood. On the other hand, cognitive behavioral therapy (CBT) has a wide variety of modules which focus on problem solving, treating the challenges of daily life as represented by phobias, problem behaviors (e.g., substance abuse, social anxiety, general anxiety disorder), and current issues which may rise out of past history."
Dr. Barber, though, hesitates to dismiss psychoanalysis, saying, "There is lots of evidence that psychodynamic therapy is effective, despite the widely held belief that cognitive behavioral therapists believe it is not."
3. What should you ask potential therapists when narrowing down your options?
So you've decided you'd like to see a therapist, and you plan to try out a few until you find a good fit. How do you decide what a "good fit" looks like?
Most therapists will ask new patients a few questions that help them understand what the patient wants from therapy. Lindau says she asks patients what they would like to talk about, when the issue began, and how often they feel it affects them. "I want to know how they decided to call me, and that question usually elicits the description of their reasons for calling," she says. This is an important time for potential therapists to learn about you, but the reverse is true too.
It's also important to consider each potential therapist's particular specialty. "It can be very reassuring for the client to work with a therapist who has training and experience in treating the problem for which you are seeking assistance," says Lindau. "As a therapist, I find I am more effective with people who seek my assistance for [my specialty, which is] severe depression."
4. What should you do before the first visit?
Like with any doctor's visit, it's important to prepare for your first meeting by bringing all necessary materials, like your insurance information (if applicable) and medical history. But for therapy, it's also helpful to reflect on your goals and think about your reasons for coming in.
"These won't necessarily be the same goals a year later, but think about what's bringing you in — if it's a relationship, depression, an eating disorder," says Dr. Barber. "It doesn't mean you'll only be working on these, but you should be thinking quite a bit about not just the symptoms, but also the underlying reasons. You might be feeling down, but why? It's a lot of homework, but a good therapist will help you even on the first session."
But it's also completely OK to not have all of this figured out! "If you don't really know exactly what you need help with, the first stage of therapy will be to identify it," Dr. Barber says.
5. How (and when???) do you know if it's a good match?
There's no hard-and-fast rule about how quickly you'll determine whether you and your therapist are a good match, but it's common to have a gut feeling within the first couple sessions. That doesn't mean your instinct is always right, though: If you're doubting whether or not you like your therapist, it's worthwhile to consider why.
"You may want to listen to your heart, but if the reason you don't like your therapist is something you find you don't like about people in general, you should question that," says Dr. Barber. "It might be something you'll end up working on."
Dr. Barber also suggests explicitly asking your therapist in those first few sessions how he's viewed the visits, and seeing how his ideas for treatment align with yours. "Something I'd get from a therapist — after the first visit, or a few — is a summary of what they think you should be working on. Check in with them."
6. When (and how often) should you meet?
Therapists often meet with their clients once a week for an hour or half hour, but this can vary from person to person. For many, like Lindau, the weekly meeting is a good time frame because "the client has the experience of using the skills s/he has learned in treatment." For others, meeting times can range from twice a week to once a month or longer — it all depends on what your therapist deems most appropriate for you and what you are comfortable with.
Unfortunately, many therapists run regular business hours, so it can be hard to schedule appointments during the work week. If evening or weekend hours are something you need, that's another factor to consider when searching around. If you're seeking therapy in college or an educational institution, they are often more flexible about hours, and will be understanding of your student schedule.
7. What about medication?
Going to a therapist doesn't necessarily mean getting medicated, but if it's something you have questions about, those are important to bring up with your therapist. Just don't be surprised if she advises you to wait a bit.
"If you come to therapy for something like depression, and you're not medicated, and it hasn't gotten any better after two to three months, then I think it's time to think about medication," says Dr. Barber.
If together you decide that medication is the right option for you, very often you'll be referred to a separate provider. Most psychologists and therapists aren't licensed to prescribe medications, and many psychiatrists don't practice therapy — but your therapist will likely have appropriate recommendations.
In the best-case scenario, your therapist and psychiatrist will be in contact with each other — especially following the early diagnostic visits — though Dr. Barber says, unfortunately, that isn't always the case. Keep your therapist clued in and let her (and your psychiatrist) know about any concerns you have or side effects you experience.
8. What if you don't have insurance?
Don't let a lack of health insurance stop you from seeking out care — many therapists, including Lindau, offer options for uninsured patients. "I am willing to negotiate a sliding scale and," she says. "And even if I am not on their provider list, some insurance companies will cover my services because I provide a specific treatment that has a solid reputation for helping the clients with whom I work."
Depending on your insurance plan, you might get partial reimbursement for appointments with a provider who isn't in your network; just call ahead to find out exactly what you're allowed. Many facilities also offer affordable community health care, including mental health services. Mental Health America has a helpful page of resources for finding low-cost options, as does Patient Advocate Foundation.
9. Can you search for a therapist who shares your identity?
Therapy works best when you are comfortable with your therapist, so people may often seek out therapists who share their identity. When you're "shopping around," it is perfectly acceptable to ask to see a therapist based on a shared identity, like race or gender, and it is common to see this kind of information listed on therapists' websites as well.
Of course, this isn't to say that people who don't match your identity will be unable to help you, just that these backgrounds will be more helpful to some than others. For Dr. Barber, it is all about comfort. "Take, for instance, a woman who has been raped. A lot of women who have been raped will want to see a female therapist, they're more comfortable with that. Is that better for them, will it make a difference? There's no real evidence. But the fact is that that's what you want, what will get you to therapy — why question it? If you have a strong preference, then go with it."
10. How safe is your private information?
According to the American Psychological Association (APA), the Health Insurance Portability and Accountability Act (HIPAA) dictates a national standard of privacy that protects patients' medical records and health information — meaning, what you say to your therapist or psychiatrist really does stay between you and your therapist or psychiatrist. This is especially a relief for people who share a therapist with family members, friends, or co-workers.
But there are exceptions: the law requires a psychologist to share your information, with or without your consent, if she believes you pose a risk to yourself or others; if she's made aware of ongoing domestic abuse or neglect; or — in an extreme and unlikely case — if she receives a court order for it. If you use insurance to pay for your therapy, the insurance company will receive information about diagnosis and treatment, but they are also bound by the same HIPAA confidentiality rules. Of course, these rights are as they apply to adults; laws for minors vary more state by state, but often parents, patients, and therapists will work together to agree on terms of privacy.
11. What should your relationship with your therapist be like?
Regular meetings and intimate, confidential conversation can make one's relationship with their therapist feel, at times, like friendship, but professionals caution against confusing the two. "Some clients may feel close to their therapists because of the intensity of the material shared," says Lindau. However, she says: "This relationship is professional and should remain so even after termination — the therapist is not the client's best friend."
It's important to maintain boundaries, for both parties, says Barber. "Your therapist shouldn't be your best friend insofar as you shouldn't be discussing what you ate for lunch — it can happen sometimes, and that's fine, but it shouldn't be all the time." Still, that doesn't mean your therapist doesn't care. "They are your friend in the sense that they will listen, worry about you, care about you. They should be invested in you for your own good, not their own needs. That's what's important."
12. How do you distinguish a good therapist from a bad one?
It's important to remember that therapists and counselors are first and foremost human beings, and by extension, neither all-knowing nor infallible. Just because a person is a therapist, doesn't mean he's a good one — but what does a bad therapist look like?
The answer, of course, isn't completely universal, but there are some red flags. If you feel like the boundary of professionalism isn't being upheld — say, your therapist talks too much about his own life; passes judgment on your lifestyle or habits; touches you without your consent; is confrontational or argumentative; blurs the therapist-patient relationship by becoming too friendly, suggesting social activities, or leaning on your professional skills (for example, if you're a tutor, your therapist shouldn't ask you to come by and help his son prep for the SATs) — it means you aren't getting what you need, and there's no reason to stick around to see if it gets better.
But if you're feeling more generally uncomfortable, or unsure that your treatment is actually helping, bring that up in your session. A good way to gauge the quality of the care you're getting is to be direct about any concerns you have and see how your therapist reacts. "Good therapists are comfortable with honest and transparent conversations about your progress and, if it's stuck or lacking, are open to trying different approaches or taking different tacks," writes psychoanalyst Michael Bader for Huffington Post. "Problematic therapists are covertly defensive, always throwing the question of progress back in your lap and, therefore, appearing to avoid their responsibility for at least half of what's going on."
13. What happens when it's time to stop seeing your therapist?
Your relationship with your therapist, like any relationship, is one that requires a lot of effort and emotional energy. Naturally, therapist breakups can be hard. If you want to stop seeing them because you are dissatisfied with their service, it is perfectly appropriate to say, "I don't think this is working" and move on, says Lindau — and conversely, "for the therapist to say, I don't think this is the right time for you to do this type of treatment."
In other cases, you may have been seeing a therapist for a long time and need to move, or your therapist may tell you that he thinks you don't need to see him anymore. These kinds of situations can be difficult because these relationships can be a big part of our lives, and it may be hard to let them go. But it is important to deal with this uncomfortable moment. "There's something about saying good-bye, and it's good to call before the next session instead of just not showing up," Barber says. "I also think it's worthwhile to have the discussion, even if it is uncomfortable. Part of psychotherapy, in general, is going through the uncomfortable and learning from that, even though it's difficult."