What Happens in a First Therapy Session

A first therapy session is mostly an interview, and both people are conducting one.

Most of the anxiety about it comes from not knowing the shape of the hour. There is no couch, no silence waiting to be filled, and no expectation that you arrive with a clear account of yourself. If you could describe the problem cleanly you would probably not need the appointment.

‍

Before the hour starts

Many practices begin with a short consultation call rather than a full session. Fifteen or twenty minutes, free, aimed at a single question: is this the right person for this problem. It is worth taking. A referral elsewhere at that stage costs you twenty minutes instead of six weeks.

There will be paperwork. Contact details, emergency contact, insurance if relevant, and consent forms covering confidentiality and its limits. Filling it in beforehand leaves the hour for the conversation.

‍

What gets asked

The first session is an assessment, so the questions are broader than the problem you came in with.

• What brought you now. The now matters. Something usually changed.
• How the problem shows up in an ordinary week. Specifics, not summaries.
• How long it has been going on, and whether it has come and gone.
• Sleep, appetite, alcohol, substances, medication.
• Previous therapy, what helped and what did not.
• Work, family, who is around you.
• Safety questions, including about self-harm and suicidal thoughts.

That last one is asked of everyone. It is routine, not a reaction to you, and answering honestly does not trigger anything automatic. Therapists ask because not asking is worse practice.

‍

What you do not have to do

You do not have to tell the whole story in the first hour. Saying that a subject exists and that you are not ready to open it yet is a complete and reasonable answer. A therapist who pushes past that is telling you something useful about how the rest would go.

You do not have to have a goal ready. Working out what you actually want is often the first piece of work rather than a prerequisite.

You do not have to be in crisis to deserve the appointment. A large share of therapy is done by people whose lives look fine and are not working the way they want them to.

‍

What you should ask

The fit matters more than the credentials on the wall, and you can only assess it by asking.

• Based on what I have described, how would you approach this
• What would the first couple of months look like
• What would I be doing between sessions
• How will we know whether it is working
• Have you worked with this before

Clear answers are a good sign. So is a therapist who says this is not their area and names someone whose area it is.

‍

Leaving the first session

People often feel worse that evening. Saying things out loud for the first time is tiring, and a session that stirred something up is not a session that went badly.

What to check afterwards is narrower than whether you liked them. Did they understand the problem as you experience it. Could you follow their account of what would happen next. Was there any sense of being judged. Fit is not a personality match, and two or three sessions is a fair window before deciding.

If it is not right, saying so is allowed and is not an insult. Therapists expect it and would rather hear it than have someone quietly stop booking.

‍

Where to go next

How DBT differs from talk therapy is useful if your picture of therapy is two chairs and a friendly ear. How DBT built on CBT covers where the two fit together, and who DBT is for answers the diagnosis question.

At Axis Psychological Services in New York City the first step is a short consultation with Dr. Jesse Finkelstein. You can read how the work is structured or book a free consultation.

If worry or panic is what is bringing you in, you can read how anxiety and panic therapy in NYC is structured before your first call.