Getting started in psychotherapy: A guide for new clients

Psychotherapy remains a mysterious and daunting practice for many people. My hope here is to provide a short introduction of “need to know’s” so that you can make an informed decision and get the most out of therapy should you choose to do it. 

How to choose the right therapist

To begin with it will be useful for you to know, broadly speaking, what actually makes psychotherapy work. Counter to what many people believe, and counter to marketing principles, the type of therapy one practices is much less important than the type of person the therapist is. That is to say that a therapist's kindness, empathy, warmth, honesty and courage do more to create change than any particular therapeutic school, technique or intervention. Look for the qualities of a good human being, rather than a particular kind of therapy (CBT, EMDR, IFS etc.). Of course, these human qualities are not quite enough, and it is important to ensure that your therapist also has the relevant qualifications. 

Therapy takes time

How much time? There are no hard and fast rules and everybody is different. However, there are a number of general guidelines you should take into consideration when beginning your psychotherapy. Firstly, there is a very clear “dose-response” relationship between the amount of therapy one receives and the amount of improvement one sees. At the risk of oversimplifying, the longer people stay in the therapy the more they improve. The most exhaustive study on this found that after 21 sessions, 50% of clients see clinically significant change. It took more than 40 sessions (almost a year of weekly therapy) for 75% to see significant change.

 We can confidently say that, on average, meaningful change begins at about 6 months of weekly therapy and grows from there. Some people will get what they need from much less; others from much more. Change is difficult and costly in many facets of life. This is no less true when trying to change oneself. In fact, learning any skill requires a significant investment of time and energy. Why would psychotherapy be any different?

The therapeutic relationship

As discussed, the relationship between you and your therapist is of primary importance. But what do we actually mean by “the therapeutic relationship”? Many people are confused about this (therapists included). They take it to mean that you and your therapist like each other, or that there are “good vibes” in the room. Of course, having good rapport is not a bad thing, and can be a sign that a good therapeutic relationship is under way. However, this is only one component of what makes up a good therapeutic relationship. As therapists, we must also attend to other factors within the therapeutic relationship. 

Shared purpose/understanding (why are we here?)

Alongside good attachment and rapport, there should be a very clear, shared understanding of what’s brought you to therapy in the first place. What’s wrong? What do you need help with? It can take some time for this to become clear to both you and your therapist, but it is essential to good therapy. Otherwise treatment becomes vague and unclear. 

Your therapist should have a good case formulation, meaning they should be able to have some idea about what’s bringing you to therapy, and they should be able to articulate this in a way which makes sense to you. 

There is, however, a difference between the presenting problem/symptom and the shared purpose of the work together. This is because the presenting symptom can have a vast number of causes behind it. The shared purpose should be toward addressing that underlying cause. 

For example, two people both present to therapy with depression. The first person feels depressed because they are ruthlessly self-critical, with one part of the mind endlessly attacking another part. The second person feels depressed because they have become entirely dependent on other people, and when those people aren’t there for them they feel an acute sense of abandonment and loss, which drives their depression. The symptom is the same, but the underlying cause is different. It is not enough to say that the purpose of the work is to “feel less depressed”. The shared purpose should be focused toward the underlying psychological causes rather than the observable, manifest symptoms. This leads into the last factor making up the therapeutic relationship, the means. 

The means (what are we going to do?)

This refers to informed consent. It is important that you know what therapy involves and what the plan of action is to get you to your goals. Many people come to therapy unsure about how it works and it is our job as therapists to explain this to you. A treatment plan emerges out of the shared purpose of the work and will help you to build a mental picture of what a mutual therapeutic arrangement really looks like. 

We typically work to help you understand what makes therapy most effective, for instance encouraging spontaneous, emotionally expressive speech; being open and honest about feelings toward your therapist; an explanation of any interventions that might be used; explaining our role in working to link your emotions to your cognition etc.

When there is good rapport and attachment, a shared purpose for the work and a clear, mutual understanding (treatment plan) the therapeutic relationship is working.

Common Obstacles

Avoidance is probably the number one barrier to people getting the help they need through therapy. Most people drop out of therapy within the first 10 sessions, well before reaching a clinically significant threshold. Sometimes there are perfectly legitimate reasons for ceasing treatment or dropping out of therapy, but it is often due to some underlying avoidance or resistance. 

There will be times when you don’t want to go to therapy. Life gets busy, there are work demands and family obligations. Be prepared to face and encounter this resistance to the process and be willing to talk about those feelings with your therapist. 

In my experience, this pulling away often comes up when something emotionally important is on the threshold of awareness. If you stick with it, you may discover something important about yourself. Be open and honest about any of your doubts and hesitations with your therapist. If your therapist becomes angry or defensive or dismissive - you should find a new one. 

The Therapeutic Frame

The therapeutic frame refers to the reliable conditions under which the therapy will take place. The frame should be made explicit by your therapist and mutually agreed upon. It includes factors like the length of sessions, the fee, how to handle cancellations and missed sessions, anticipated difficulties, frequency of sessions, clarifying goals, confidentiality, informed consent and navigating encounters outside of therapy. The frame is essential to maintaining a sense of safety, predictability and consistency for both the therapist and the client. 

Progress in Psychotherapy

All good therapists understand that progress in psychotherapy is not linear. Some people may even feel a bit worse in the beginning. This is because coming into contact with thoughts and feelings that have been avoided or unconscious may be a necessary part of the therapeutic process. This is normal, and not necessarily a sign that therapy isn’t working for you. 

In saying that, if your sessions are causing extreme dysregulation or dysfunction, there may be an issue with the pacing of the work. You should talk to your therapist about this as you may need to back off or slow down. If they ignore you or continue to encourage you to aggressively go after traumatic memories - you should find a new therapist.