Is it normal to become really anxious before a therapy appointment?
Joyce Marter, LCPC, responds:
It is completely normal to be nervous or anxious before attending a therapy session, especially your first one. Many people do not know quite what to expect from their first session and feel some ambivalence or apprehension about beginning the process of counseling. For some, the feelings of anxiety last beyond the first session and may occur before the appointments during the initial phase of therapy or recur at various points in the treatment when addressing critical issues. This anxiety is understandable because people often share and explore things in therapy that are extremely personal and important to them (i.e. feelings, experiences, relationship issues, and other concerns) and this may trigger some feelings of vulnerability or overwhelm. After more than 15 years of counseling clients, I recommend that you consider the following solutions to common pre-therapy jitters.
Problem: “I don’t know what to expect.”
Solution: Ask your therapist what to expect during the first session when you schedule the appointment. Most often, a therapist’s office is set up a little more like a living room (with couches or comfortable chairs) than a typical workplace environment or doctor’s office. The therapist usually has some paperwork for you to complete that is much like the paperwork would receive at any doctor’s visit. The paperwork is used to demographic and insurance information, will include a statement of understanding that reviews the limits of confidentiality and fees for services, HIPAA information and perhaps a release to speak with other treatment professionals such as your primary care physician or psychiatrist.) You will be asked about your presenting issue, which is the reason you are seeking therapy. Your therapist may ask a number of questions about your symptoms and your psychosocial history (emotional, familial and relationship history.) The therapist will likely summarize his or her first impressions of your presenting issues and outline a general treatment plan (for example weekly therapy and/or referrals to other resources such as support groups, etc.) You should feel free to ask any questions or state specifically what you are looking for out of counseling. For example, I have many clients tell me in an initial session that they are looking for somebody who has a more direct approach, rather than somebody who is going to simply ask how they feel and then nod. It is also helpful to share if you have had previous experiences in therapy and what you liked or didn’t like about those treatment episodes. This will help you and your therapist establish the best working relationship.
In the first session, I explain to clients that therapy has three phases. The first is about information gathering, where the therapist may ask many questions in an effort to get to know the client and assess the presenting issues. The second phase is the meat of the treatment and this is when the therapist and client collaborate to make positive changes in the client’s thinking, self-care, emotional regulation, communication, support network, etc. The third phase is termination and this occurs when the client is feeling much better and the client and therapist begin to process the end of treatment.
I usually tell my clients to think about coming to therapy once a week (therapy sessions typically run 45-60 minutes, some therapists may allow more time for up to 90 minutes for first sessions or couples/family sessions) for at least 12 weeks. Some therapists may do shorter term work, but I feel this is a good estimate of the minimum length of treatment. Many clients stay in therapy longer than that, especially if they have deeper or longer standing issues, or if they simply want to keep improving and moving forward. Often, as a client makes progress in treatment, the visits will be less frequent, perhaps every other week or once a month. The end of therapy is a very important phase that should be processed directly with your therapist, rather than just canceling an appointment and never going back. This is because the termination or endings of relationships are a critical part of wrapping up the work and getting closure. Very often, I have former clients return to therapy periodically for “tune-ups”, which is a normal, proactive and positive thing to do.
Problem: “I’m afraid my therapist will judge me or think I’m crazy.”
Solution: Know that your therapist is there to help you, not to judge you. Your therapist is a human being and is not perfect. He or she understands that psychological, substance abuse and relationship issues are a normal part of the human condition. More than likely, anything you share with your therapist he or she has heard before, or heard something more extreme. Your therapist knows that we all have issues and that your issues are how you are, not who you are. Nobody is perfect and we all have our issues and our work to do. In fact, most therapists have been in therapy themselves, as it is a recommended aspect of our training and work in the field. Remember that for all of us, our fears of what others think of us is often a projection of our own inner critic onto them. In other words, it is really your own negative beliefs about yourself that you are imagining the therapist might think about you.
Problem: “I am afraid of revisiting painful memories or disclosing embarrassing issues.”
Solution: You do not need to share all of your inner secrets at your first session, nor should you. The beginning phase of therapy is about building a trusting therapeutic rapport and relationship. You can share things at a rate that feels comfortable for you. Numerous times, I have had clients indicate that they experienced a bigger trauma in the past (like childhood sexual abuse or rape,) that they are not ready to address. This is a healthy way of being open and honest with your therapist, and also setting boundaries and pacing the therapy at a rate that feels comfortable for you. As you establish a stronger therapeutic rapport and when your therapist knows you are ready, you can collaboratively work together to address those experiences. Many clients report feeling tremendous relief that sharing those experiences wasn’t as difficult or scary as they thought and they are able to process those memories in a way that is more manageable. If you have a significant trauma background, select a therapist who specializes in trauma and treatment modalities such as EMDR.
Again, your therapist is not there to judge you and you can improve your prognosis in therapy by sharing as much as you can when you feel ready. The beauty of therapy is that it is a confidential relationship and you do not need to see your therapist outside of sessions. The therapy office can be your own safe place to share these experiences without judgement.
Problem: “I worry that my therapist is going to expect me to make changes that I am not ready to make.”
Solution: Many people fear that their therapist is going to expect them to immediately abstain from any self-sabotaging coping mechanisms such as substance abuse, self-harm or eating disordered behaviors, for example. They might also worry that the therapist is going to want them to end a dysfunctional or abusive relationship that perhaps they are not ready to leave. Therapists are trained to meet the client “where they are at,” meaning they respect where clients are at in the process of change. Furthermore, therapists know that people only change when they are ready and when they want to change. Often, I let clients know that their negative relationship patterns or self-sabotaging behaviors will likely continue during the first phase of treatment, or they may recur at various points in the therapeutic process. This is normal and expected and I encourage my clients to be open and honest with me, because I will not judge them and it will help them the most to share these behaviors or relapses with me.
Problem: “I don’t know if I will like or “click” with my therapist.”
Solution: Many therapists offer a complimentary mini-consultation either over the phone or in the office. This is a good time to ask them about their therapeutic style, approach, or areas of expertise. Feel free to ask them any questions you might have.
Furthermore, it is normal for clients to meet with 2-3 different therapists for an initial session as a way to find the right fit. Therapists understand not everyone is going to be a match for them and that this “therapist shopping” is often a normal part of the process. See who makes you feel the most safe and comfortable, as well as who seems to best understand and be equipped to help you move forward.
The therapeutic relationship is the foundation of treatment. It takes time to establish a therapeutic rapport and trusting, collaborative working relationship. Empower yourself to ask your therapist questions and/or voice any concerns that you have about your treatment. Express any feelings of anxiety open and directly. I always encourage clients to be direct with me about any negative feelings that they are having about me, anything I have said, or the therapeutic process. Openly discussing these matters will allow you to do honest and effective work. Often, having a positive therapeutic relationship will help you have more positive relationships outside of the therapy room because you are learning how to communicate in a way that is open, honest and respectful of yourself and others.
Problem: “I felt worse after my therapy session and am nervous about the next.”
Solution: Understand that it is normal for things to get a little worse before they get better during the initial phase of therapy. I always say, therapy is like cleaning out a messy closet. If you have ever had a closet that you have crammed a bunch of stuff into over the years, starting therapy is a little like deciding it is time to clean it out. Deciding to do the work is a daunting task that requires courage and commitment. Typically the first phase of cleaning out a closet is pulling a bunch of things out and spreading them around the room. Similarly, the beginning of therapy is an information gathering period where the therapist asks about the client’s psychosocial history (i.e. family, relationship, substance use, work history, etc.). Just like the beginning phase of cleaning out a closet, the beginning phase of therapy can be overwhelming. People might wish that they just left things alone because they might be feeling even more of a mess now. This is a normal phase and I encourage clients to understand this is a anticipated part of the process and to stick with it. In therapy, we are eventually able to let go of some things, and rework what is left so that the person (like an organized closet) is functioning and feeling better.
It is also normal for these negative or worsening feelings to get triggered at various points in the therapeutic process, especially if you and your therapist are hitting on some core issues. Some resistance and defensiveness on your part is normal, those feelings are there to protect you. However, you can work through them by expressing them to your therapist and continuing in treatment knowing that relief and growth are on their way.
Above all, congratulate yourself on beginning in therapy and doing your psychological, relational, career, or even spiritual work. You are working on healing and evolving, which will deeply and profoundly improve your life and positively influence those around you. Reframe your nervousness as excitement because you are taking forward steps on the path to healing, wellness and achieving your best self personally and professionally.
Joyce Marter has been a Licensed Clinical Professional Counselor (LCPC) since 1998 and is owner of Urban Balance, an insurance-friendly counseling practice with over 40 therapists and five locations in Chicagoland. She was selected by Crain’s Chicago Business for the “40 Under 40” list of 2010. Marter received her Masters Degree in Counseling Psychology from Northwestern University and was awarded Distinguished Alumni of the Year in 2008. She currently serves as the Vice President of the Board of the Illinois Mental Health Counselors Association and an Editorial Advisor for Wellness Times. Marter has been consulted as a psychological exper/t on television, radio and in publications such as “The Wall Street Journal” and “U.S. News”.
Posted by CJ Newton, MA, Therapists.com Editor on September 17, 2012 at 05:00 AM