The first therapy session

The first appointment is usually not therapy. It is an assessment: a conversation whose purpose is to work out what the difficulty is, how severe it is, and what sort of help would suit it. Knowing that in advance removes a good deal of the dread, because the pressure to perform, or to arrive with the problem already neatly described, comes from expecting the wrong thing.

Which route, and who you meet

Through the NHS, the first contact is often a telephone assessment, typically half an hour or so, with a practitioner who will probably not be the person who goes on to treat you. They will ask what has been happening and for how long, and will usually go through standard questionnaires about mood, anxiety and how much the difficulty is interfering with ordinary life. Those scores are not a verdict; they are used to decide what to offer and, later, to see whether it is working.

What follows depends on what emerged — guided self-help with a practitioner checking in, a group course, individual therapy, or a referral somewhere more specialist. There may be a wait between the assessment and the start of treatment, and it is reasonable to ask at the end of the call roughly how long it will be and what to do if things get worse in the meantime.

Privately, the first appointment is usually with the therapist themselves, lasts the full session, and doubles as a chance for both people to decide whether to go on. Fees, frequency and cancellation terms should be set out before it, not discovered afterwards.

What the hour is actually like

A session is conventionally fifty minutes. Arriving a little early helps, partly for any forms and partly because walking in flustered uses up the first ten minutes.

The room is an ordinary room with two chairs. Nobody is required to lie on a couch, whatever the cartoons suggest. The therapist will introduce themselves and will usually begin by explaining how they work, what the sessions will involve, and what confidentiality does and does not cover — and if they do not, those are fair things to ask at the start rather than at the end.

Then they will ask some version of: what brought you here, and why now. The second half of that question is often the more useful one, since something has usually changed to turn a long-standing difficulty into an appointment.

There is no need to have it organised. "I don't really know, I just can't carry on like this" is a complete and perfectly workable answer. So is bringing a list. So is saying several things at once and being asked which to start with. Nobody is marking the account for coherence, and the therapist's job includes helping to find the shape of it.

Expect questions about sleep, appetite, concentration, alcohol and drugs, work, money, relationships, physical health and medication, and something about family and childhood. Not out of nosiness — each of those changes what is likely to help.

The question people dread

At some point in an assessment, almost everybody is asked whether they have had thoughts of harming themselves, or of not wanting to be alive.

It is worth knowing in advance that this is asked of everyone, that it is asked in order to make sure the right level of help is offered rather than to catch anybody out, and that answering honestly does not set off anything dramatic. People are not removed from their homes for saying yes to a question. What a yes does change is the urgency and the kind of support offered — which is the point of asking, and the reason that an honest answer gets someone better help faster than a careful one.

Confidentiality, and notes

What is said in the room stays in it, with a small number of well-defined exceptions that a therapist should explain at the outset: where there is a serious risk to the person's life or to someone else's, where a child or vulnerable adult may be at risk, and where a court requires disclosure. NHS services also keep records within the clinical team and will usually write to the GP.

Every therapist also has clinical supervision — a more experienced practitioner with whom they discuss their work. That is a requirement of good practice rather than a breach of confidence, and clients are usually anonymised in it. It is a reasonable thing to ask about.

Notes are normal. Someone writing while you talk is paying attention, not losing it, and most therapists write less in the session than people imagine. Recording a session, on the other hand, is not routine and requires explicit consent — nobody should be recorded without being asked. Notes form part of a health record, and a client is entitled to ask what is kept and to request access to it.

What to ask them

The first appointment is also an assessment in the other direction, and these are all ordinary questions:

• What training do you have, and which register are you on?
• Have you worked with this kind of difficulty before?
• What approach do you use, and why that one for this?
• Roughly how many sessions, and how will we know whether it is working?
• What happens if it is not working, or if I want to stop?
• How do I contact you between sessions, and what happens in a crisis?

A practitioner who answers these straightforwardly is demonstrating something useful. One who is put out by being asked is also demonstrating something useful.

Afterwards

People expect to feel better and are often surprised. Relief is common; so is feeling wrung out, exposed, oddly flat, or as though too much was said too soon. Some people cry in the car. Some feel nothing at all and conclude it was pointless. A heaviness for the rest of the day is common enough to be unremarkable.

None of that means it went badly. Talking about difficult things is tiring, and the first session usually stirs up more than it settles. It is worth not scheduling anything demanding immediately afterwards, if that can be arranged.

If it is not the right person

One session is a poor test of whether therapy will help. It is a reasonable test of whether this is someone you can talk to — and those are different questions.

Not going back is allowed, and needs no justification. Saying so is easier than not saying so: a short message that the fit does not feel right is enough, and a good therapist will not argue, may offer to discuss it, and can often suggest a colleague who would suit better. Through an NHS service, it is possible to ask to be seen by someone else.

What is worth avoiding is quietly giving up on therapy altogether because the first person was wrong. Fit varies enormously, and the relationship between client and therapist is one of the better predictors of whether therapy works at all — which is precisely why a mismatch is worth acting on rather than enduring.

See also choosing a therapist and mental health, which lists the routes to help and the crisis lines.