The summer before I turned 28, I felt like I was swimming through a hot, sour fog. I was exhausted all the time, but I also couldn’t sleep, and sometimes I’d wake up in the middle of the night and cry. My eating habits got weird. I started second-guessing everything I did at work. There was no objective “crisis” — my job, friends, relationship, and family were all fine, in general — which made me even more anxious about what was wrong with me (but seriously, what was wrong with me?!). Finally, after a few months of this, I decided to figure out how to find a therapist.
Here, I had a big advantage: my best friend from high school happens to be a clinical social worker, and she helped me pinpoint the type of approach I wanted (a mix of different backgrounds, but not too woo-woo) and sift through contenders online. I made a list and started emailing possible candidates.
My “shopping” period was blessedly brief, but eye-opening as far as red flags go. The first person I saw quickly suggested that maybe I was dissatisfied with my life because — no joke — I wanted “more simple things, like to get married and have children.” (Not exactly a psychological diagnosis.) Onto therapist number two, who seemed thoughtful and kind … until she nodded off about 30 minutes in. (I know that boring your shrink to sleep is a thing, but really — our first session?)
Losing steam but spurred on by my therapist friend, I trudged to appointment number three. The woman who opened the door was warm, insightful, and reassuring. I liked her voice and her demeanor. I couldn’t quite describe why, but after I saw her, I felt clearer and calmer. A few sessions later, I found myself repeating things she’d said to me in conversations with other people. I continued to see her on and off for years.
Not everyone is lucky enough to have a good friend to guide them through the process of starting therapy, but with the right information, you’ll be well-equipped to do it on your own. Yes, it’ll take time and effort, which may be in short supply when you’re wading through piles of whatever life has dumped at your feet. But ironically, the more daunting the process may seem, the more you may benefit from the results. Here’s what you need to know before you start, even if you’re a total beginner.
1. When should you go to therapy in the first place?
People often think you need to be in the middle of a true “emergency” to seek therapy — the big stuff like a breakup or divorce, the death or illness of a loved one, a job loss, addiction issues, etc. But really, therapy can be appropriate at any time, provided you want to be there. “If you’re thinking, ‘Maybe I should try therapy,’ then it’s a good time to go to therapy,” says Satya Doyle Byock, a licensed psychotherapist and owner of Quarter-Life Counseling in Portland, Oregon. “The longer you put that off, the more complicated the process becomes.”
Another common time to seek therapy is during a big life change, like if you’re moving to a new city, graduating from college, starting a new job, or becoming a parent. “There are lots of transitional, non-crisis moments when people still need support,” says Robin Tovell-Toubal, a licensed mental health counselor based in Chapel Hill, North Carolina. “We also see a lot of people coming to sessions with a more general feeling that something’s not right, and they want to explore different areas of dissatisfaction with where they are versus where they think they should be.” (Which basically sums up 27-year-old me.)
2. What types of therapy are typically practiced, and how do you know what might work best for you?
There are many different camps in the therapy world, and yet more subsets within them. (You can find a comprehensive list of these different types — also known as modalities — on Psychology Today’s website, with accompanying descriptions, as well as a shorter guide to the most common ones here.) Many therapists are also trained in multiple methods, while others are highly specialized; it’s important to ask your therapist about their modality of choice, and whether they think it will be helpful to you, before you make your first appointment.
Two of the most popular types of therapy are cognitive-behavioral therapy (or CBT) and psychodynamic therapy (or PDT). Here’s a very quick run-down.
Cognitive-behavioral therapy, or CBT, focuses on identifying unhealthy behavior patterns (say, compulsive shopping) and the negative, unrealistic thoughts that drive them (“If I don’t have these nice clothes, people won’t like or respect me”). Then the therapist will work with the patient to replace those misleading thoughts with more accurate ones (“Actually, people will like me just as much if I don’t buy these clothes”), thereby leading to better coping mechanisms. The therapist might assign worksheets or other homework so that you can monitor your thought and behavior patterns on your own.
Boatloads of research has shown that CBT can be highly effective in treating everything from PTSD to more generalized anxiety, but critics say that it doesn’t always get at the underlying causes of those symptoms — which may, in some cases, lead to symptoms returning over time.
If your issues are more vague and/or deep-seated, then you may want to consider a psychodynamic approach. This is closer to what many people think of when they envision traditional therapy: It involves delving more into your past, including your upbringing and family relationships, to help you understand and resolve old conflicts so that you don’t project them onto the present. Research has shown PDT to be most effective in treating depression, some anxiety disorders, eating disorders and somatic disorders (when physical symptoms, like stomach aches, which are due to psychological stress rather than physiological illness). The treatment will require patience, a lot of talking, and a willingness to deal with a less structured and more exploratory process.
3. Where should you even start to look for the right therapist?
Many of my friends have found their therapists through other friends’ referrals, which certainly isn’t a bad place to start. (In fact, one of my best friends now sees my old therapist.) But you should also be sensitive to whether your friend is comfortable sharing her therapist with you. Also, some therapists have personal policies against seeing people who are close to one another. In either of those cases, you could ask that the therapist to refer you to a colleague. “Therapists often have great networks in their area, and can guide you to someone with a similar approach if they aren’t able to see you themselves,” says Tovell-Toubal.
Alternatively, there’s the internet. Depending on where you live, you can probably find a local mental health organization that lists licensed practitioners in the area, says Byock. If you’re hoping to be covered by insurance, you can also search within your insurance plan’s database. Byock recommends cross-checking the names you find in multiple directories (or just straight-up googling the therapists’ name), in case they have a personal website or other profile with more information. But be aware that many therapists don’t have a big online footprint. “A lot of therapists actually don’t have that much of an internet presence,” says Byock. “That doesn’t mean that they’re bad therapists. In fact, it might mean they’re good therapists who are so booked that they don’t have time to market themselves.”
The best way to find out is to get in touch with them yourself. Aim for a list of about five potential therapists to start, says Tovell-Toubal. “Hopefully, you’ll find what you’re looking for before you get to the fifth one.”
4. What’s the deal with insurance?
Unfortunately, many therapists don’t take insurance directly. (In insurance terms, they’re “out-of-network.”) But it’s possible to get your insurance to cover at least part of the cost, depending on your plan. “It’s very difficult for therapists to bill insurance companies these days, so a lot of them will give you a receipt that you can then pass on to your insurance company and try and get reimbursed yourself,” says Tovell-Toubal.
The reimbursement process is annoying to figure out (I’ve been there), but pretty easy to maintain once you know the process. The best way to muddle through is to set aside some time, pick up the phone, and call the number on the back of your insurance card. Ask to be referred to someone who can answer questions about mental health benefits (some insurance companies have special representatives just for that). You’ll have to listen to hold muzak, but once you get a human on the line, ask what kind of coverage they provide. If they will reimburse a portion of your therapy bills (or all of them, if you’ve got a really great plan), the next steps are pretty easy: You just mail off your therapy receipts every month with a special insurance form, and you’ll get a check back in the mail once the paperwork is processed.
Be aware, however, that you will have to get a clinical diagnosis from your therapist in order for insurance to cover treatment. “If you want to use your health insurance, the therapist has to document the diagnosis in a medical record and in the billing system that your insurance company uses to process claims,” explains Tovell-Toubal. You’ll probably receive this diagnosis after the first or second session, and ideally, your therapist will discuss it with you (you should also feel free to ask). If you are seeking treatment for a very specific disorder, such as anorexia or PTSD, then that’ll go in your record; if you are there for less comprehensive reasons (like I was), then you might receive a more general diagnosis, like mild depression or anxiety.
5. What should you do before the first session?
Once you’ve got your list of potential therapists, reach out over email or phone. Don’t be discouraged if they don’t have openings, or can’t work with your schedule or insurance; this is why you have backups. They should understand your constraints, and if they can’t accommodate them, they may be able to suggest a different therapist who can.
In addition to hammering out logistics (appointment times, location, fee), ask about the therapist’s background and outlook, either on a short call (15 minutes or less), or via email. “You want to get a sense of the therapist’s relationship to their work,” says Byock. “I recommend questions like, ‘Have you been in therapy yourself?’ And, ‘What made you decide to become a therapist?’ That will help set a foundation for what’s going to happen during therapy, and why you both are in the room together.”
You can also ask about the therapist’s experience in dealing with your demographic or community, says Tovell-Toubal. “For example, if you’re in your 30s and the therapist specializes in treating children, you probably want to know that before you make an appointment. I’ve also been asked questions like, ‘Have you had experience with the LGBTQ community?’ Or, ‘Are you religious?’”
It’s totally fine if you feel more comfortable with a therapist who has a similar cultural background to your own, or who speaks Spanish, or has a certain gender identity. But also, be open. A good therapist might help you explore some of these requirements in a way that makes you more flexible.
6. How should you discuss the therapist’s fee?
Therapists are trained to manage this discussion, but it may still be awkward, especially if it’s a stretch for you to afford the costs. You should have a sense of the fee before you arrive for your first appointment, which you will be billed for (some therapists don’t charge for the first session, but the vast majority do). Don’t walk into anything that you truly can’t pay for, but know that you can talk to your therapist about ways to make it more affordable. A lot of therapists charge on a sliding scale, which means they are willing to provide some leeway.
If you’re really strapped, Byock recommends looking for a supervised, unlicensed intern (emphasis on supervised — they should be able to provide the name of their supervisor, who should be licensed, for you to double-check if you want). “Interns are building their practice and must complete a certain number of hours of supervised clinical work in order to get their license, so they have a great reason to be working early with people who can’t afford a full fee,” says Byock. “They can also be great clinicians.”
7. Any red flags to look out for at the first appointment?
When you go to your first appointment, pay close attention to how you physically feel in the room. Is the temperature okay? Can you sit comfortably on the furniture? Is there a weird smell? Do you feel like you have your therapist’s full attention, or is there a distracting computer screen or beeping sound or spider on the ceiling? Does the space feel private and safe? If not, bring it up to the therapist. These things don’t have to be immediate deal-breakers, but be aware of your body and do your best to communicate what you’re experiencing in the moment.
Some anxiety is normal, but again, try to mention it when it’s happening (“I feel a little dizzy/my stomach feels tight/I don’t know what to do with my hands,” etc.). It might feel strange to verbalize these things, but therapists go through extensive training to listen and respond to what you’re saying. Most will welcome this information, because it helps them help you.
Ultimately, you should feel a strong connection to your therapist, says Byock. “It’s a relationship, and there needs to be some fundamental chemistry. Your therapist should be someone you want to speak to, and who you look forward to seeing even when the work gets difficult.”
Things to watch out for: “You should feel like your therapist is totally present with you during your session. They should not be multi-tasking unless it’s directly related to your therapy,” says Byock. “They should also never fall asleep on you, which happens.” (Yep.) But your therapist is human, she adds, and sometimes their mistakes can be a fruitful part of your work together. “If they do something that bothers you, the critical question is, can you talk to them about it? And can they appropriately apologize, or respond in a way that is non-defensive and maintains boundaries? Repair and reconnection is a very basic part of the way we develop trust.”
8. How do you know if it’s “working”?
“If you don’t feel you’ve made progress after four to five meetings with someone, then you need to think about switching therapists,” says Tovell-Toubal. What counts as progress is up to you – you can’t expect to check off boxes. And you certainly can’t expect your therapist to “fix” you. “Even the most genius therapists in the world aren’t going to be able to change someone’s timeline for growth,” says Byock. “You also have a responsibility to try to push the relationship in a new direction.”