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Wednesday, February 24, 2010

Starting Psychotherapy: It's Not Unusual to Feel Anxious or Ambivalent

Even the most motivated people who start psychotherapy often feel anxious and ambivalent about beginning to see a psychotherapist. As a psychotherapist, I understand that this is often a common reaction to beginning the psychotherapeutic process.

Why Do People Feel Often Anxious and Ambivalent About Starting Psychotherapy?
In general, making changes can be challenging for many people, even when they know they need to make these changes and they feel the time is right.

Starting Therapy:  It's Not Unusual to Feel Anxious or Ambivalent

Most people decide to begin psychotherapy because they want to make certain changes in their lives. But even when we know that we can benefit from making changes or that the people around us might also benefit, change can be scary.

We're familiar with our old habits and ways of being. Even when we've become uncomfortable with those ways or they're not working for us any more, often, when we think about what it might be like to be different, we're faced with the unknown:

"How can I make these changes?"
"Will I be able to do it?"
"I've tried before to change, and it didn't work. Will this be just another unsuccessful attempt?"
"What if I change and my family and friends don't like these changes in me?"

It's not unusual for doubts to start to creep in our minds when we begin thinking about making changes.

If you've never been in psychotherapy before, the psychotherapy process is very different from anything that you've done before.

Starting Psychotherapy:  It's Not Unusual to Feel Anxious or Ambivalent

To begin with, you need to find someone to see and that's not always easy. Many people like to try to see someone on their insurance plan, but many psychotherapists have dropped off managed care insurance panels because many managed care companies have been cutting their fees to therapists to the point where therapists can no longer sustain their private practices and meet overhead expenses.

Even if they don't cut fees, most managed care companies have not raised their fees in over 20 years, so the fees are not keeping pace with therapists' overhead expenses, like rents in Manhattan offices. So, there is that challenge, which can be frustrating.

I usually recommend going with recommendations from people that you trust, like friends or doctors. If you find a therapist that you like who is not on your managed care panel, you might have mixed feelings about paying for your therapy out of pocket.

But when you stop to think about how you spend money in other areas of your life (maybe you pay $10 a day for cigarettes or you think nothing of spending $100 for dinner and drinks with friends), ask yourself if it's worth it to spend the money to make the necessary changes that you want to make.

After you find a psychotherapist that is either recommended to you or you find on the Internet, you might feel awkward about making that first call: What will you say? How can you explain what you want in a way that is concise but still gets across what you're looking for? Often, you'll get the therapist's voicemail when the therapist is in session: What do you say? Where do you want to be contacted?

People often find that after they've managed to find a therapist, call and set up an appointment, they feel good about making a commitment to change. They feel that they've set an intention to make changes in their lives--they've started the process with that phone call.

 But it's not unusual to have mixed feelings about it at the same time. Some people worry prior to the appointment, anticipating what the therapist might be like: "Will the therapist be judgmental?" "Will the therapist think I'm crazy?" and so on.

For many people, coming to the first appointment can be anxiety provoking. Usually, even the most anxious people settle down after a while. They might find starting difficult, but a skilled therapist can help them to feel comfortable so they can use their session in a productive and satisfying way.

I usually like to provide a vignette that illustrates the points that I'm making in my blog posts because I think that it helps to clarify these points.

 My vignettes are always composites of actual cases, which means that they are made up of several different cases, with all identifying information changed to protect confidentiality.

The following vignette is an example of the affects of anxiety and ambivalence when a new client is starting psychotherapy:

Daniel:

Before Daniel called me to set up a psychotherapy consultation, he had been thinking about starting psychotherapy for several years. In the past, he had gone through the process of getting recommendations for psychotherapists from friends and his doctor, but he was too anxious to follow through with making the phone call to set an appointment.

When he called me the first time, he was so anxious about leaving a message that he forgot to leave his telephone number, so I couldn't call him back. Fortunately, he realized that he forgot to leave his number, so he called back, got my voicemail again and left a call back number so I was able to call him.

When I called Daniel back, I sensed that he was very anxious about making the appointment, so we spent a few minutes talking about what he was looking for in therapy.

As we continued to talk, I could hear that Daniel's anxiety was starting to decrease. He was able to say that he felt his low self esteem was getting in the way of his personal and work-related relationships and he wanted to overcome his poor sense of self. We set up an appointment and, as I usually do, I gave directions to Daniel about how to get to my office, explained the intercom system, and that when I buzz him in, he would wait for me in my reception area.

On the day of the appointment, I received a call from Daniel that he had misplaced my office address. I sensed that this was due, in part, to Daniel's anxiety about coming to our appointment, so I gave him the address again and tried to allay his anxiety. On his way to the appointment, Daniel got stuck on the subway, which increased his anxiety but, fortunately, he had left himself a lot of extra time, so he arrived early for his appointment.

When he arrived in my reception area, due to his anxiety, Daniel forgot that I told him that I would be with another client before him and that he could wait in the reception area for me to to get him after the prior client's session. So, he got to the reception area and he wasn't sure what to do. My office is set up so that the door between the reception area and my office is locked, for safety as well as confidentiality purposes (so clients don't accidentally walk in on another client's session).

 Soon after he arrived, which was about 20 minutes early, I began to hear him calling out in the reception area, "Hello? Is anyone here?" So, I came out of my session with the client who was in my office, introduced myself and told Daniel that I would be with him in 20 minutes. I pointed to the magazines in the reception area and told him that he could choose one of them to read while he was waiting, which he agreed to do.

When I came back out to meet Daniel again in 20 minutes, I noticed that he looked very anxious and he was sweating profusely. I invited him to sit wherever he was comfortable in my office, and we were about to begin the session when Daniel told me that he just remembered that he needed to make an important phone call, and he would be right back. I waited a few minutes, but Daniel never came back that day. He left in a state of panic. After I called him later that evening, he told me that he bolted out of the office because he panicked.

During our next session, Daniel was still anxious, but he was able to talk about his fears about beginning therapy. I encouraged him to ask questions and to express his concerns. Gradually, over time, Daniel began to settle into the therapeutic process. His doubts didn't disappear over night, but he was able to express them, look at them more objectively, and feel safer and more comfortable coming to his sessions.

Starting Therapy: Daniel Was Anxious During the First Session

Like most clients who begin attending psychotherapy, Daniel began to learn how to use therapy by actively participating in treatment and with my assistance. Most skilled therapists know that new clients need psychoeducation about psychotherapy to help them begin the process.

As Daniel became accustomed to the process, his comfort level increased and his anxiety level decreased. He still often had mixed feelings about "what it meant" that he was in therapy, but those feelings also decreased over time.

Starting Therapy: As Daniel Became Accustomed to the Process, He Became More Comfortable


Helpful Tips About Starting Psychotherapy:
  • Realize that most people are anxious and ambivalent about starting psychotherapy and, if you're feeling this way, you're having the same experience that most people have.
  • Recognize that it might be hard these days to find a psychotherapist on your managed care panel.
  • Ask people that you trust, including friends and your doctor, for recommendations
  • Before you make that first call, recognize that it's normal to feel anxious, so think about what you want to say before you call.
  • Recognize that procrastination won't make you feel any less anxious. If anything, delaying making the call might make you feel more anxious as doubts and fears creep into your thoughts and might cause you to lose your resolve about starting psychotherapy.
  • Think about your financial priorities if you choose to call a therapist who is not on your managed care panel. While it's true that many people really can't afford to pay for therapy out of pocket, especially during these difficult financial times, often people can afford it, if they're willing to make some changes in how they spend their money and if they can find a therapist who works on a sliding scale.
  • Give yourself plenty of time to get to your appointment.
  • Recognize that most psychotherapists see clients back to back, so there is often a client in the therapist's office ahead of you.
  • Take a few deep breaths, read a magazine, do a crossword puzzle, or listen to music quietly on your Ipod while you're waiting for the therapist to come out to greet you.
  • Recognize that the initial consultation session is a time to talk about what brings you to therapy at this point in time. Many people have only a vague sense that their lives are not working for them or that they're not happy. But they might not know what the problem is or why they're not happy. This is completely fine and it's all part of the process. If you're not sure what's wrong, finding out will be part of your process in therapy. You don't have to come in with the answers. A skilled therapist can help you through this process.
  • Try to get a sense of whether you feel comfortable with the therapist. People often don't know this from one or two sessions because of their own anxiety. It's often hard to distinguish your own anxiety about being in therapy from a discomfort that you might feel with a particular psychotherapist. So, it might take you a few sessions to sense if you have a rapport with the therapist.
  • Assuming that you're able to separate out your own anxiety about the psychotherapeutic process from a lack of rapport with a particular therapist, don't hesitate to tell the therapist that you're feeling uncomfortable or that he/she might not be a good fit. Most therapists know that a good rapport is necessary for treatment to go well, and will not be offended by this.
  • Recognize that there are different types of psychotherapy (psychodynamic psychotherapy, cognitive behavioral therapy, EMDR, clinical hypnosis, and so on). Most therapists will explain during the consultation session the different types of therapy that they do and might refer you to websites or give you written information. If you're unclear, ask questions. You're not expected to be knowledgeable about this.
  • Know that, with few exceptions (smoking cessation being the most common example), most forms of psychotherapy, even EMDR and clinical hypnosis, which are often recognized to be faster and more effective, are not "quick fix" solutions. The therapy process is often an investment in time and money for you and you need to weigh this against where you are now in your life and where you want to be.
  • Ask questions. It's appropriate and often helpful to know about a therapist's professional background, education, and expertise. Make sure you see a therapist who is licensed in your state. Most therapists will not answer personal questions about themselves because you are the focus of the therapy and not them. But if you have a need to be with a particular kind of therapist (e.g., you're gay and you want to be with an "out" gay therapist), you can explore this with the therapist. Some therapists will divulge this information, if they think it's important to your therapeutic process, most will explore the meaning of your questions first and then divulge the information, and others will not. It's often a matter of style and professional training.
I hope this post was helpful to people who are thinking about beginning psychotherapy. I've confined my remarks to the beginning of the process because people often have difficulty starting.

I am a licensed psychotherapist, hypnotherapist and EMDR therapist in NYC. I work with both individuals and couples.

To find out more about me, visit my website: Josephine Ferraro, LCSW - NYC Psychotherapist

To set up a consultation, call me at (212) 726-1006 or email me: josephineolivia@aol.com.