Your first therapy session: what to expect and how to prepare

What happens in a first therapy session?

• Introductions. “Your therapist should spend a few minutes introducing themselves and explaining how they work.” You can ask about their qualifications and experience^[1].
• Assessment. They may ask whether you would like to give a history of the problems you are having, ask you to fill in some forms, or simply ask you to “tell your story”^[1]. One NHS talking therapies service sends a questionnaire before every session^[3].
• Contracting. You agree the terms: how long sessions last, how often you meet, and how information about you will be protected^[1][4]. You should get a record of what you agreed, or easy access to one^[4].

Topics can include your relationships, your childhood, your feelings and thoughts, your behaviour, past and present events, and situations you find difficult. What comes up depends on you and on how the therapist works^[1]. A counsellor will “listen to you without judgement” and try to see things from your point of view, but “Counsellors do not usually give advice or tell you what to do”^[2].

The first session is also your chance to see whether this therapist is right for you. The BACP calls it “important for making sure that you feel comfortable with your therapist and their way of working”^[1]. The US National Institute of Mental Health (NIMH) says simply: “Rapport and trust are essential”^[5].

Feeling unsure about starting is allowed. The BACP’s ethical code says “Hesitant clients… will have their reservations acknowledged and taken into account”^[4].

How to prepare for your first therapy session

You do not have to prepare, but knowing what to expect helps. In a review of 17 studies, people who were prepared for therapy beforehand, with an explanation of how it works and what their part is, were less likely to stop early and had somewhat better results at the end^[6]. People who start with more hopeful expectations also tend to do a little better, although that is a link, not proof that hope does the work^[7].

Checklist for an online session

• A room where you will not be overheard or interrupted, with the door closed
• Headphones, so the conversation stays private
• A charged laptop or phone, propped up so you do not have to hold it
• The video link opened a few minutes early, with camera and microphone tested
• A backup plan if the call drops, such as a way to message your therapist
• Notifications turned off on your phone and computer
• Water, tissues, and your notes and questions within reach

These are practical suggestions from us, not research findings.

What to say in your first therapy session

You do not need a speech. Many therapists will simply ask you to “tell your story”, and what matters is that “you feel you’ve had the opportunity to tell the therapist about what’s troubling you”^[1]. If you do not know where to start, try one of these openers. They are our suggestions, not a script:

• “I’m not sure where to start, but…”
• “The main reason I’m here is…”
• “I’m nervous about this.”
• “Something happened recently, and I keep thinking about it.”
• “I’d like to talk about this, but not that, yet.”

You set the pace. You do not have to tell everything in the first hour, and it is fine to say you are not ready to talk about something yet. If you go blank or get upset, you can simply say so.

Honesty helps most. The BACP says: “You’ll get the best results from your therapy if you’re open and honest with your therapist and say how you’re really feeling.” That includes how you feel about the therapy itself^[1]. Under its ethical code, therapists should review your progress from time to time and, when practicable, ask your views on how you are working together^[4].

Questions to ask your therapist

You are allowed to interview your therapist. NIMH says a first conversation can help you understand how treatment will go and whether you feel comfortable with the therapist^[5], and the BACP suggests asking about their way of working^[8]. Choose the questions that matter most to you:

1. What are your qualifications, and where are you registered or licensed?^[5][8]
2. Have you worked with people with problems like mine?^[5]
3. What approach will you use, and why do you think it fits?^[5]
4. What would our goals be, and how will we know if it is working?^[5]
5. How often will we meet, and roughly how many sessions do you expect?^[5]
6. What happens if I am not starting to feel better?^[5]
7. Are there any limits to confidentiality?^[5][9]
8. What do you charge, and what happens if I cancel or miss a session?^[5][8]
9. How should I prepare for each session?^[9]
10. How does ending therapy work, if I decide to stop?^[9]

Some of these come from a list written by young adults at the Depression and Bipolar Support Alliance, a US patient charity^[9]. If your therapist names an approach you do not know, our guide to types of therapy explains the main ones, including CBT.

Is what you say in therapy confidential?

Yes, with limits. A good therapist will explain those limits at the start, before you share anything difficult.

An NHS talking therapies service in Devon puts it plainly: “What you share in therapy will remain confidential.” But “if we are concerned about your safety, the safety of others, or your wellbeing, we may need to involve other services”, and “Wherever possible, we will discuss this with you beforehand”^[3]. The BACP’s ethical code asks therapists to tell clients in advance about any limits they can foresee^[4]. The main ones are:

• Serious harm: to protect you or someone else from serious harm, including safeguarding, for example if a child may be at risk^[4].
• The law: when the law requires or allows them to share information^[4].
• Supervision: therapists regularly meet a supervisor to review their work^[3], and this is one of the limits they should tell you about^[4].

In the US, the federal privacy rule for health providers (HIPAA) lets a provider covered by it share information if they believe in good faith it is “necessary to prevent or lessen a serious and imminent threat to the health or safety of a person or the public”^[10]. Rules also differ between states and countries, so ask how it works where your therapist practises. The simplest way to find out is to ask in your first session: “Are there limits to confidentiality?”^[5]

Online or in person: does it make a difference?

For common problems, the research so far says not much. A review of 47 studies found therapy “no less efficacious when delivered via videoconferencing than in-person”, with the strongest evidence for CBT and for anxiety, depression and PTSD^[11].

There are two caveats. The working relationship may be a little weaker by video, though that result was inconclusive and symptoms improved about as much^[12]. And there is much less evidence for severe conditions: one review found no trials it could include for schizophrenia or bipolar disorder^[13]. If you have a severe or complex condition, ask a doctor what kind of care fits.

Talking therapy can be done in person, by video or phone, or as an online course^[14], and the BACP calls online or phone counselling “a flexible and accessible option”^[8].

Therapy in your own language

If you think and feel in another language, it is worth asking for a therapist who speaks it. The BACP says: “If English is not your first language, you can ask if it’s possible to have a therapist who speaks your preferred language”^[8], and its own directory lets you filter therapists by language^[15]. UK guidance for anxiety says: “Consider providing all interventions in the preferred language of the person with GAD if possible”^[16].

Research points the same way, with caveats. A 2006 review of 76 studies, mostly with ethnic minority groups in the US, found that therapy adapted to clients’ culture helped, and that it worked better when it was delivered in the client’s own language^[17]. The evidence is older, so treat it as a sign, not a rule.

On Bliss Therapy

On Bliss Therapy you choose a therapist yourself from their profiles, who speaks your language, by video, with no waitlist. 52 psychologists and counsellors list anxiety and stress, with sessions from €30 (about £25). Between them they speak 23 languages. See how it works or browse all our therapists.

Is this the right therapist for me?

How well you and your therapist work together matters. Across 295 studies and more than 30,000 patients, a stronger working relationship, meaning agreement on goals and tasks and a good bond, was linked with better results. The link was moderate, held across types of therapy and countries, and was about the same for online therapy^[18]. It is a link, not proof that the relationship alone makes therapy work. The BACP’s view is that “Your relationship with your therapist is usually the most important factor in the success of your therapy”^[8].

After your first session, ask yourself: did I feel listened to? Could I be honest? Did their way of working make sense to me? NIMH says “it’s important that you feel comfortable with the therapist and have confidence in their expertise”^[5]. It can take more than one session to know. If it does not feel right, you have options:

• Say so. You should be able to give your therapist honest feedback on how you feel about the therapy and how you are working together^[1].
• Talk it through. If you have been going for a while and are not getting better, NIMH’s advice is to “talk to your therapist”, and you might explore other professionals or approaches^[5].
• Change therapist. In the BACP’s words, “You don’t have to continue with a therapist if you can’t relate to them or don’t feel safe”^[1].

Stopping early is common: across 669 studies, about 1 in 5 adults left therapy before it was finished^[20]. People who get the kind of therapy they prefer drop out less and do slightly better^[19], although those studies looked mostly at preferences for a type of therapy, not at choosing a therapist from a profile. On Bliss Therapy you pick the therapist yourself, so if the first one is not right, you can choose someone else.

After the session: how you might feel and what comes next

Talking about painful things can stir things up. An NHS talking therapies service is honest about it: “therapy can be hard and sometimes it can make you feel worse before you start to feel better”^[3].

That is different from getting steadily worse. In depression trials, 5% of people in therapy got worse, compared with 12% to 13% in the comparison groups^[21]. If you keep feeling worse, tell your therapist. Questionnaires that track how you are doing can help here: for people who were predicted to do poorly, feeding that progress back to therapists reduced the number who got worse^[22].

Next, you and your therapist agree how often to meet and roughly how many sessions you need^[1]. It varies. In routine services, helpful courses ranged from 4 to 26 sessions depending on the setting and the problem, more of the progress tended to come early on, and weekly sessions seemed to speed things up^[23]. Ask your therapist what they would expect for you.

How to check a therapist’s qualifications

In the UK

Several titles are not protected. “The job title ‘psychologist’, is not, by itself, protected by law”, and neither are counsellor, psychotherapist or therapist. Nine titles are, including clinical and counselling psychologist: anyone using one must be on the HCPC Register, and misusing one is a criminal offence^[24]. You can search the register by name^[25].

For counsellors and psychotherapists, the BACP warns that “Anyone can call themselves a counsellor or psychotherapist and set up in private practice”^[15]. The NHS advises choosing someone on a register accredited by the Professional Standards Authority (PSA), such as the BACP^[2][14]. Our guide to the difference between a psychologist, psychiatrist and counsellor explains the titles.

In the US

NIMH says most psychotherapy is with “a licensed mental health professional”, who may be a psychiatrist, psychologist, social worker, counsellor or psychiatric nurse, and suggests asking about their credentials, experience and any specialty^[5]. Ask which licence your therapist holds, and check it with the body that issues it where they practise.

Our therapists are based outside the UK and the US, so they are unlikely to be on UK registers or covered by US health insurance. Ask any therapist about their training and their registration in the country where they practise.

Wherever you are, the BACP’s advice holds: “Find out about your therapist’s professional memberships, experience and qualifications, and ask them to explain what they mean”^[8].

When therapy is not the right first step

Therapy is not an emergency service. If you are thinking about ending your life, or you or someone else is in danger now, do not wait for an appointment: get help straight away. As the NHS says, “A mental health emergency should be taken as seriously as a physical one”^[26]. In the US, the 988 Lifeline “is available 24/7/365. Your conversations are free and confidential”^[27].