As a therapist I am often asked “What happens in therapy?”. Sometimes people ask “What do I have to do in therapy?”. So here’s an overview to give some comfort and confidence to those considering therapy. I’m keen to hear from other therapists and the experiences of those who have attended therapy. What do you think would be useful for those about to embark on their therapy journey? Please remember, it is YOUR therapy. You really can’t “get it wrong”. I’ve tried to anticipate the various questions – but let me know of others. What happens in therapy?
What is “Talking Therapy”?
Psychotherapy and counselling are known as “talking therapies”. So a core element of therapy will be you talking about your feelings, thoughts and/or behaviours.
Many people find this challenging. But your therapist will help you. The therapist should create a safe and confidential space for you. And he or she should build your trust and confidence to talk about sometimes difficult subjects.
Remember that you have control in therapy
Remember that YOU are the client. And most therapists will focus on what you want (and don’t want) in therapy. Therapists respect your autonomy. Most therapists are non-directive – which means that they will let you to decide what you do and don’t talk about – and how and when – in therapy.
If something feels uncomfortable or “not right” in therapy, please share this with your therapist. Or with the nominated person to whom your therapist should direct you.
And remember that as a client you can’t “get it wrong”!
How do I choose a therapist?
Different types of therapists have different approaches to therapy. So therapy sessions might look and feel different depending on whether you have, for example, a Person-Centred, Psychodynamic or a CBT therapist.
For example:
CBT – The therapist will probably be a little more directive and will ask you to use your brain (cognitive) abilities to think about things differently. They may also ask you to do “homework” such as keeping a journal or logging your emotions and thoughts between sessions
Psychodynamic – Psychodynamic therapists may be quiet and simply encourage you to talk. But they will be listening carefully to what you say. And they will likely encourage you to explore your past. They may act like a “blank slate” and appear to not say very much.
Person-Centred or Humanist – These therapists follow the work of Carl Rogers. A general law of interpersonal relationships?. They will work hard at developing empathy (seeing things from your point of view An introduction to emotional intelligence (EQ) and empathy (Video)), being honest (congruent) and non-judgemental (this is called “Universal Positive Regard”).
There are many other types of therapist – and they often use different tools. For example, some may use psychoeducation and encourage you to read or listen to other materials. Some may encourage you to write or draw in sessions – or to work with a tray of objects. Some may help you develop new skills – such as how to calm down and relax, to talk to others in a non-confrontational way or to implement boundaries in behaviour.
You may choose an Integrative Therapist, which means that the therapist selects whichever approach and tools he or she thinks will suit you best.
I explored the subject of choosing a therapist – and different types of therapy – here: How do you choose a therapist? – Kim Tasso
What happens before therapy starts?
Usually, a therapist will invite you to a short telephone call or online session of about 15-30 minutes – without charge – for an initial conversation.
This is both to help you assess whether you would feel comfortable working with that therapist and to help the therapist assess whether they have the qualifications, skills and experience that is right for you. Sometimes, clients need to see a therapist who specialises in a particular topic (for example, trauma or couples therapy).
It may be that the therapist refers you to another therapist. Or the therapist may suggest you speak to another health professional – such as a GP or a psychiatrist. Or it may turn out that you would prefer to work with a different therapist.
So this initial conversation is for you both to decide whether and how you proceed with therapy.
If you decide to proceed you will agree the date, time, location and cost of your first session. The therapist may send you some documents such as a contract or working agreement, the location details and/or some initial assessments.
What happens during my first therapy session?
Again, this will vary depending on you and your therapist. Remember that you are the client and you can share with your therapist what you do and don’t want to do.
But there are some things that will often happen in the first session as therapists must adhere to some professional rules.
For example, in a first session the therapist is likely to talk through the components of a contract or working agreement. This document describes how you and the therapist will work together. In effect, it is setting out the boundaries of the therapeutic relationship.
A critical element of the working agreement concerns confidentiality – a therapist will not share anything you disclose during therapy unless some very specific situations arise (e.g. a risk to yourself or others, legal requirements etc). So, in most regards, what happens in therapy, stays in therapy.
Some clients do not realise that all therapists need to discuss their clients with their supervisors. The supervisor is usually a more experienced therapist who will check that your therapist is behaving professionally and competently – and they may offer additional guidance and ideas to your therapist. It is like a “quality” check on your therapist and in other ways it means that you get a “second opinion” and other ideas on how therapy may help you. Your therapist will usually keep your details anonymous in supervision. But all supervisors have to maintain confidentiality as part of their professional conduct.
It also describes things like what will (and won’t happen) within and between sessions, how payments are made and similar matters. And what happens if you are unhappy with the therapy service provided. It should also explain the professional rules (e.g. NCPS | Code of Ethics or BACP Ethical Framework for the Counselling Professions) that govern the therapist’s behaviour and what to do if you wish to complain.
Sometimes in early sessions, the therapist may ask you to complete one or more assessments. Sometimes these are to explore the issues you want to talk about. Sometimes these are so you can monitor any changes or improvements. Sometimes these assessments are simply the therapist asking you questions. On other occasions, this may involve you completing forms (either a paper version or online) or assessments. They might even provide an assessment to learn what you would and would not like to happen during therapy (for example, the Cooper-Norcross Inventory of Preferences (C-NIP)).
Will there be tests and assessments in therapy?
Some therapists may ask you to complete assessments – either with them during a session or between sessions online. You cannot “pass or fail” these assessments. They are a tool to help you and the therapist understand what is happening to you and which tools and approaches you may find useful in therapy sessions.
You don’t have to complete these assessments if you don’t want to. And if your therapist doesn’t suggest any – and you might find them useful – then please ask about them.
And remember that the information from your assessments is confidential.
Is it OK to feel impatient in therapy?
Some clients may be frustrated that early sessions use time to consider the working agreement and assessments. Because they want to start talking about what has brought them to therapy straightaway.
This is understandable. However, while you discuss agreements and assessments, it gives you time to feel comfortable with and trust your therapist. And it also enables the therapist to learn about you and what has brought you to therapy so that he or she knows how to ensure therapy will be of most value to you.
Sometimes, the therapist may need to check that you have the necessary emotional and mental resilience to talk about very difficult topics (for example, assaults and other types of trauma).
Some clients may feel that the therapy isn’t having an impact. That’s OK. Sometimes it can take time for therapy to promote any noticeable impact. Sometimes you can be in therapy for a while for you to notice changes and improvements.
Remember that you may have spent your whole life feeling or thinking a certain way. You may have developed habits or coping strategies that served you when you were younger, but are no longer working for you. It takes time to help your brain process things and change. And it takes time for your brain to learn to feel or think in a different way to how you have felt or thought your entire life. Be kind and patient with yourself.
Sometimes you might feel worse before you start feeling better. No two people have the same experience of therapy. We are all different.
Let your therapist know if you are feeling impatient – with yourself, with the therapy or with the therapist.
What do I want from therapy?
Usually in the first or an early therapy session, your therapist will ask you what you want to achieve with therapy. Sometimes clients find this a difficult question to answer. And that’s OK.
Clients have as many different reasons for going to therapy as there are different clients. For example, you may wish to feel better or less miserable. You may be trying to understand yourself. You may find that your mind keeps repeating the same (negative) thoughts. You may be finding relationships – with your partner, family or friends – tricky.
You may be anxious or stressed. You may be managing a serious physical or mental health challenge. You may be struggling with grief, loss or change. You may wish to explore and resolve key events or traumatic incidents in your life. Some clients feel afraid or at a loss with their suicidal feelings. Clients bring all sorts of things to therapy – some things may seem significant, and some things may feel trivial. But if it matters to you, then it will matter to your therapist.
Usually, clients want some change to occur – they want to change the way they feel or think or behave. Your therapist should help you explore and articulate what you want to be different in the future.
It may take you a few sessions to understand what you want from therapy. And sometimes clients find that when they achieve their initial goals, they find other things that they want to address in therapy.
Whatever you do is OK. Your therapist will want you to be honest about sharing what you want so that he or she knows the best way to proceed with therapy.
What do I say in therapy?
You can say pretty much whatever you like in therapy. It is your time.
But when you therapist knows a little more about you and what you want to achieve in therapy, he or she will ask questions to encourage you to talk about topics that will relate to your reasons for seeking therapy.
There are no right or wrong answers in therapy. The key is that you and the therapist work out what needs to explored and what questions and/or issues to address.
Just take your time. It can take a while to gather your thoughts, access your memories or recall things you haven’t thought about for a while. It can take time to feel confident enough to talk about difficult feelings or thoughts. Some clients worry what their therapist might think about them if they share difficult thoughts and feelings. But therapists are trained to listen. And to listen without judgement. Your therapist should be your ally – to help you identify and talk about the things that matter to you.
Some clients find it difficult to talk about their emotions or how they are feeling. So it may take time for you to feel comfortable talking about some things. Just take your time.
Does therapy always involve talking about the past?
Many psychological challenges have their roots in your past – in your childhood and teen years. So sometimes therapy will look at your relationships with your caregivers when you were younger – your mum and your dad and your grandparents and siblings and anyone else who played a major part in your care.
However, some mental health challenges are related to your physiology. For example, neurodiverse people (who may have autism or ADHD or other conditions) and those taking some medications may find that this changes the way they think and feel. In these cases, the therapy may not talk about the past but focus on what is happening now and what you want to happen in the future.
If you don’t really want to talk about the past, then some types of therapy might be more suitable. For example, Gestalt therapists concentrate on talking about the “here and now”. They help focus the conversation on what is happening in the room between the therapist and the client in the present moment. Cognitive Behaviour Therapy (CBT) usually focuses on what you are feeling, thinking and doing in the present and how this might change in the future.
How long will therapy last?
This is a tricky question to answer as all clients are different. Sometimes, clients are in therapy for a short while. And others remain in therapy for a long time. Again, you are in control.
A few clients may find that they only need one session – and there is something called “Single Session Therapy”.
Many therapists will work on the basis of a limited number of sessions. Usually, six or eight sessions. And if therapy needs to continue longer, then they will review everything with you every six or eight sessions.
Sometimes, clients need long term therapy. And they may work with their therapist for a year or even several years.
It will also depend on the nature of the issues you want to address in therapy. And how serious or severe the issues are. And how quickly (or not) you achieve the change you seek.
So you really should talk to your therapist about this. Obviously, if you are paying for therapy yourself then you will need to know for how long you will need to fund therapy. So explore your expectations with your therapist.
Usually, your therapist will talk about when therapy might end. And they will often suggest that you have a final therapy session to review the work that you do together and between sessions.
What does it mean when therapists talk about “doing the work”?
It can be hard to do therapy. You have to feel, think and talk about things that may be challenging or uncomfortable. You may have to remember situations from the past – sometimes uncomfortable ones.
By talking about things in therapy, you may start thinking about other things. You may start to think differently. And all of this – and changing – takes a lot of mental energy.
If, as a result of therapy, you decide to do things in a different way in future then this too will take effort. Whenever we, as humans, change and grow, it takes effort. And that is what it means when we talk about “doing the work” of therapy.
But remember that in some ways it is like looking after your physical health. You often hear people say about fitness training or going to the gym “No pain, No gain”. It’s similar when you start looking after your mental health.
What if I don’t like my therapist?
Therapists, like people, come in all shapes and sizes. And, like in ordinary life, there are some people that we are likely to get on with more than others. We can’t all get on with everybody.
It is important that you feel comfortable with your therapist. Research indicates that the most important aspect of successful therapy is the relationship you form with your therapist. So be a little patient and see how things go for the first few sessions. You may find that you start to feel more comfortable with your therapist.
But if you don’t like your therapist, then please share that with him or her. They will understand. And they may be able to help you find another therapist that you will feel more comfortable with.
What if I am unhappy about my therapy?
You are the client. And if you are unhappy with your therapy or therapist then you should say so.
Hopefully, your therapist will understand. And he or she may be able to help you find a therapist with whom you are more comfortable.
I hope that you have found this useful. Please let me know – either through email or a telephone call –if you have any other questions. I will do my best to direct you to the relevant information sources.
Please remember that if you are experiencing acute issues or an emergency please contact the emergency services – Where to get urgent help for mental health – NHS
Related articles about therapy and counselling
Please also refer to my therapy site: Tasso Talking Therapy
There is also a Facebook page “Kim Talking Therapy” where I post helpful material regularly on therapy and mental health themes.
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