What’s therapy like?
It depends, but some themes should be common across good experiences.
There’s a huge variety of theories, interventions, styles, personalities, and experiences among therapists that show up differently in session. Everybody approaches the work a bit differently and fit between a therapist and a client is a big deal, so here are some notes to consider. A few things that should be reliably expected:
1. Most Everything is Confidential. With a few exceptions, everything you talk about will be confidential and protected under counselor-client privilege. The main exceptions are (a) if there’s a risk of harm to others or yourself, (2) for coordination of care with healthcare providers, (3) for insurance reimbursement if you’re using insurance, (4) for the purposes of consultation or supervision, and (5) when subpoenaed or otherwise required for legal proceedings. Your therapist will walk you through these and other scenarios. 2. Standard Rules of Social Etiquette Don’t Apply. Therapy is inherently one-sided. You are there to talk about you and there’s no need to reciprocate with your therapist. Some therapists won’t tell you anything about them at all and will politely evade if you ask. They may tell you a bit about their own experiences, but it’s only appropriate when you stand to benefit from hearing about it. Therapy also involves your therapist saying things that may make you uncomfortable. Elsewhere you can dodge topics and questions with dismissals (e.g., “I’m fine, don’t worry about it”), avoidances (e.g., changing the topic), and defenses (e.g., justifying yourself), but your therapist will know what you’re doing and will evaluate whether you can withstand being pushed and if so, will challenge you to stay with the topic at hand. 3. The Relationship is Crucial. Regardless of your therapist’s approaches, the most important aspect is the strength of your relationship with them. You will know if you’re working with the right person if after a few sessions you feel confident that you can trust them, that they are hearing and understanding you, and they productively challenge you every now and then. Figuring this out will take some time, but I would keep these characteristics in mind. If you are genuinely confident that it’s not working out, you are always free to seek a different provider. 4. Your First Session Will Be an Intake. The goal is to gather your history across multiple domains (e.g., medical, psychological, education, work, family, social, emotional, development, substance use, etc.). You will be asked about your history of trauma and why you’re there. It might feel like a strangely and immediately personal conversation or interview. It may seem jarring, but realize that you’re in the driver’s seat and it’s up to you to share as much or as little as you are willing at any given moment. And a few things that you can expect to vary:
1. There Are All Kinds of Approaches. It’s easy to be a bit overwhelmed by all the names, terms, and acronyms thrown around in counseling if you’re missing a background in counseling or psychology. But the reality is, no matter how carefully you evaluate practitioner profiles, learn about their backgrounds, or Google their theories, every one will show up differently when you sit across from them. Their body language, tone, content, even their identities, experiences, and histories will influence their work with you. Some will have you do things like breathing exercises, movements, and worksheets. Others will let the room go silent and let you take the time in any direction. Probably the best thing you can do is obtain a referral from someone you trust. Next best is to do a bit of research, trust your gut, and take the leap. It may result in a bit of lost time and money, but you are always free to seek a different provider if it’s not working out. 2. There Are All Kinds of Outcomes. Some people have great outcomes, some make a bit of progress, some don’t make any, and some walk away worse off. There are too many variables to offer a prediction of how your treatment will go. But it’s important to set the expectation that therapy isn’t a silver bullet. A lot of people just aren’t ready for it and that’s okay. A given therapist may not be the right fit for the client no matter what they do. Something could happen outside the therapy room that ends the work too soon. But for many, therapy is exactly what they needed and they worked with the right person at the right time. There is indeed an unavoidable element of faith. So what’s therapy like at Sidebar?
I’m a cognitive guy. That means we focus on the content and frequency of what you think about and how it impacts your functioning. One of the fundamental concepts behind cognitive work is that there are bidirectional relationships between our thoughts, emotions, and behaviors. As such, a dysfunctional operation in one domain will have an undesirable impact on both of the others. That’s the stuff we find and work out. On the whole, a big part of our work is gaining awareness of those dysfunctions that apply to you. You would often know how to fix them if you were already aware of them. We don’t need to co-develop a plan for spinach in your teeth. You’d already know how to try to finagle it out, to rinse with a beverage, find a toothpick, or get some floss. But you'd need to know it's there first. So I sit, listen, and observe, and then I start bringing those observations to your attention and we sort out what may and may not be relevant to your treatment goals. When you’re armed with that awareness, you can go about working a solution because you’ve identified the problem. But other times there are problems that you haven’t had to address before and therefore don’t have a good idea of how to go about solving them. Let’s say we’ve raised that awareness, we recognize that it’s critical to our treatment goals, and we’re at a loss as to what to do about it. What then? A Hypothetical Interaction With a Client:
Here's an annotated example of how such a discussion might go. For the sake of levity, the problem here is that our client John Himp has a hole in his pants in an awkward spot that has been causing people to feel uncomfortable around him. Feel free to swap the hole for any behavioral, emotional, or mental health issue you like. Imagine that this is session three or four. The client's goals are known, a strong rapport has been built, and mutual trust has been established. Client: …and it just seems as though people are eager to end our conversations and get away from me.
Therapist: Well John, I’m going to tell you something that might be a bit tough to hear but it’s just you and me so we can work through it.
Client: Okay…
Therapist: John, there’s a hole in your pants.
Often the most meaningful moments in therapy are confrontations. This is where you gain awareness of something that may be impacting your functioning. I gently communicate that hey, you’ve got spinach in your teeth. These are also the moments that may not be available to you outside of the counseling room because your stakeholders have something to lose by bringing it up with you. Client: What? No there isn’t. Maybe there is but I’ve been traveling a lot and those scratchy airplane seats sometimes just catch and I can’t help that.
It’s common to feel the need to deny and defend yourself when being confronted with something uncomfortable. But defending yourself tends to impede progress. It keeps you thinking that there isn't a hole in your pants, or that holes in your pants are okay as long as you can justify them. Therapist: I know things have been busy and it’s hard to keep up with everything. It’s also important to know that the hole isn’t in the seat so it’s not the airplane cushions. It’s pretty high up on the leg. I can even see that you’re sporting red heart boxers. If I can see red hearts, well, that probably means other people can too.
Here the therapist believes that John is able to withstand the confrontation and pushes through his defense. Where outside of therapy, your stakeholders might allow your defenses to slide in order to preserve the peace, or instigate an unproductive conflict with a not-too-gentle pushback if they're feeling emotionally activated about your pants. Client: I can’t believe you said that to me. Ugh, you expect me to go back out there like this? Maybe this just isn’t working.
Another meaningful moment is when there’s a “rupture” in the relationship, where you’re not feeling too great about your therapist. They just called you out on an insecurity, something embarrassing, or a thing that causes shame. It’s unpleasant and you want to direct that discomfort somewhere else and your therapist happens to be sitting in front of you. But it’s important to recognize that the rupture can be a critical step just before accepting something about yourself that perhaps you were hoping to avoid. Also important to note, this reaction is what John's stakeholders are also wanting to avoid. It's probably the reason why nobody else mentioned his pants to him. It’s easier to avoid the topic altogether than to confront him and risk their relationship with him. Therapist: I completely get it. Especially realizing that other people may have been seeing something that you wish they didn’t. And here I am just throwing it out there, highlighting something difficult that must feel embarrassing to hear.
Hopefully your therapist gently catches you when a confrontation knocks you off balance. To confront something that you’re trying to avoid or even afraid of and feel comfortable and safe is a huge opportunity to realize that maybe this thing isn’t so bad. We just need to manage it. Client: Yeah. But you know, maybe I knew that the hole was there and I was just hoping that nobody could see it. So fine, I have a huge gaping hole in my pants. Great. Now what? I should just throw them away.
This is the "now what do I do" moment. It’s important to note that you can’t rely on your therapist for the actual solutions. We’re there to support you and help you figure out ways to solve things on your own. Therapist: Throw them away?
Client: They’re worthless to me if all they’re doing is embarrassing me. I’m just going to get some new pants.
An example of a common challenge is that a lot of people think in all-or-nothing terms. This is a trait that can cause an unnecessary buildup of emotional strain. Therapist: What else is wrong with the pants?
Client: Well, nothing. They’re brand new. And expensive. They feel great, look great, and fit me perfectly. But I’m getting rid of them.
Therapist: I agree, they are great pants. Though it’s worth noting that the hole appears to be at the seam, and is only a few inches long.
Client: What? Oh. [Examines pants.] Yeah I guess you’re right.
To get to a point where you can closely and comfortably look at whatever it is that is causing fear, anxiety, or difficulty in functioning is a huge deal. I know this is a hypothetical, but consider the difference between John's behavior here compared to how he first reacted to hearing about the hole. He's now able and willing to engage the problem with greater clarity. Therapist: So everything else about the pants is exactly what you want from a great pair of pants, except the hole?
Client: …I could fix the hole.
Therapist: You can definitely fix the hole. What’s the plan for that?
This is an awareness-raise that doesn’t involve a confrontation. We helped John recognize that there’s room to soften his all-or-nothing way of processing his issue. Ideally, he fixes the hole, nobody can tell that there used to be a hole, he doesn’t walk around with his heart boxers hanging out the side of his leg, and all of his problems are solved. Ideally. Yes this is a hypothetical and yes a bit silly, but the points still stand. To sum up, the process generally involves my getting to know you and your goals, we start working on raising awareness of potential cognitive, behavioral, or emotional dysfunction, and then we collaborate on a plan for addressing them and follow through. We work on achieving desired change, sustaining them, and managing relapses and new challenges until all of your objectives are met to your satisfaction.