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Allan Schwartz, Ph.D.Allan Schwartz, Ph.D.
Dr. Schwartz's Weblog

How to Start Psychotherapy: A Nervous Time for Most

Allan N. Schwartz, LCSW, Ph.D. Updated: Apr 19th 2009

 Everyone who is beginning the psychotherapeutic experience has worries and concerns that vary a lot depending on who they are, what they already know and what their problems are. There are some individuals who, when anticipating their first encounter with the psychiatrist, psychologist or clinical social worker, approach the first session with a number of trepidations having to do with what they are going to discuss.

As a result of years of experience in my private practice, along with dozens of E. Mails I receive via the Internet and Mental Help Net, there are many who fear that they:

1. Will be so anxious that they will forget the reasons why the have come for therapy.

2. Find it awkward thinking about talking to a complete stranger about their personal problems.

3. Know what they want to discuss for the first session but dread the idea that their mind will go blank and they will be silent for all the sessions.

4. Doubt that they really need psychotherapy.

5. Are extremely nervous that the therapist will tell them they were "stupid" to come in because they have no real problems.

6. Do not know how to talk about or verbalize their feelings or issues.

There are a number of ways to help oneself allay these worries. For example, there are always those people who come to the first session, and every session thereafter, with a list of the reasons why they are seeking psychotherapy. The list is not meant to be given to the therapist but to remain in the client's hands to refer to as needed. Here is a hypothetical list: "I feel or think or know that I...

1. Have a lot of trouble sleeping lately.
2. Feel very sad and tearful.
3. Feel very nervous all the time.
4. Have been fighting with my wife or husband,
5. Am always very angry and lose my temper.
6. Just lost my mother, or father or close friend or some other person important to me.
7. Am drinking more than I usually do.
8. Feel hopeless
9. Am always worrying about everything.
10. And a variety of other concerns that make a list too long for here but that you, the reader can fill in for yourself.

Actually, the relationship between psychotherapist and client begins with the first telephone contact. There are some people who ask the therapist questions over the phone. There are also some therapists who may ask for a brief reason why they are seeking therapy. There are therapists who ask no questions on the telephone and wait for the first meeting and there are patients who make the first appointment without asking questions. There is no right or wrong in any of this. Each therapist has their own style or way of handling things, as do patients.

In the same way, there are different types of therapy that are practiced. For example, if you make an appointment with a social worker or psychologist who is a psychoanalyst, they are likely to be very quiet on the phone and even during the first and subsequent sessions except to give some instructions about saying everything that comes to mind with no censorship of thoughts.

Cognitive Behavioral Therapists are more likely to have a very structured approach to the first and all session. In many ways, this allays patient anxiety because the therapist has questions and an approach that keeps both of them engaged with few silences.

There are those therapists who are eclectic in their approach. In other words, they will use a variety of approaches, depending on what they judge to be best for the client. In this way, a psychodynamic psychotherapist may have a psychoanalytic way of thinking but may ask lots of questions and make lots of comments that keep the patient thinking and interacting.

There are many more types of therapy than there is room to discuss. Regardless of the type of psychotherapist you are seeing, there is nothing wrong with bringing written notes or lists to the sessions. In fact, in Cognitive Behavioral Therapy, you will be asked to do homework assignments that require some writing. There are even those who utilize "narrative therapy" and that, too, calls upon the patient to write journals about their lives.

It is always proper to ask the therapist the type of therapy they practice. It even proper to search for the types of therapists who use the type therapy you may be searching for.

It is alright and even important to ask the therapist about their credentials and licensing so that you know you are seeing someone who is under state rules and regulations.

Keep away from any practitioner who refuses to give you information about these important issues.

I have often found that people are very confused about the types of licensed psychotherapists there are. Here is a very brief list:

1. Psychiatrist: Medical Doctor (MD) who can legally write prescriptions. Many of these no longer practice psychotherapy and use medication as their sole method of practice.

2. Licensed Clinical Psychologist: Doctor (PhD) but non medical and cannot write prescriptions except in one state. Use psychological testing and psychotherapy.

3. Licensed Clinical Social Worker: MSW and LCSW. Some continue on to PhD degrees in mental health and those are also "Doctor" if they have the PhD. They cannot write prescriptions and do not conduct psychological tests.

4. Licensed Marriage and Family Therapists: These can come from any of the mental health professionals listed above but have special training and certification to practice Marriage and Family Therapy.

Know who you are going to see and do not take the word of family and friends. Always check credentials and licenses. In fact, by using the Internet it is possible to go to the state licensing board for your state, look up the therapist and learn if any charges or law suits for malpractice were ever brought against them.

 Remember this: If you are very nervous do not feel ashamed and do not try to hide it from the therapist. In fact, it is part of the reason you are in that office. You can say you are nervous, right from the start.

Dr. Elisha Goldstein will provide additional information about psychotherapy.

Your comments and questions are always encouraged.

Allan N. Schwartz, PhD



Allan Schwartz, LCSW, Ph.D.

Readers who live in the Boulder, Colorado metro area, or in Southwest Florida may contact Dr. Schwartz for face-to-face consultation. He is also available for psychotherapy through Skype video for those who are not in Florida or Colorado. He can be reached via email at for details.

Reader Comments
Discuss this issue below or in our forums.

intimidated - - Jul 8th 2010

what if the person feels intimidated?

Dr. Dombeck's Note: Feeling intimidated or anxious is pretty common for people starting with a new therapist.  The situation is unknown and often feels threatening; the potential for embarrassment or rejection appears to be high.  I could write an entire essay on this subject but for here in this short space, let me simply say this is a situation where it is best to persevere in spite of these aversive feelings.  Therapy is a situation where you generally have "nothing to fear but fear itself" (to borrow from Churchill).  To make it easier to persevere, one strategy is to break the fearful task down into small, more managable chunks.  For instance, it is not necessary to commit to going to therapy a lot. Just agree to go the one time.  It is not necessary to talk about what you fear.  Instead, just say that you have fears.  Take some of the pressure off yourself by lowering your expectations of yourself and how vulnerable you have to be and how quickly and the task will perhaps become a little easier to manage. 

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