Everything I Wish I'd Known Before Starting Therapy
Some advice on how to make the most of your talking therapy if you’ve never had it before.
Illustrations: Calum Heath
At the age of 25, I've been in therapy for a perfect decade. That includes a child psychologist, various bouts of NHS cognitive behavioural therapy (CBT) and psychotherapy, and various private psychotherapists. If this was a marriage, it'd be a tin-slash-aluminium anniversary – a metal that supposedly represents how a successful partnership can be bent without being broken. Which is fitting, considering I've had phases of thinking of canning it altogether, convinced it isn't working, before crawling back with my tail between my legs.
At different points my therapy has been for anxiety, depression, PMDD, psychosis and periods of dissociation, mania or eating issues, as well as other things that have fallen short of clear categorisation. I absolutely can't claim to understand how therapy can work for different illnesses, and every person will respond to mental health treatment differently. Still, I've realised a lot of things through trial and error that I wish someone had told me before I started.
It's not easy to get therapy
A caveat before we begin. The NHS is severely underfunded, to the point of being near-hopeless when it comes to mental health. You will truly understand the meaning of mental health crisis when you've been on a CBT waiting list to treat depression for months, only to find out the treatment you'll receive is for half an hour, once a week, for ten weeks – and that if you miss or rearrange two sessions because you're so depressed, you're discharged. If you have a chronic mental illness and need long-term access to a psychotherapist, god help you.
That said, just because treatment is hard to get, resist feeling guilty for getting it. Don't think you aren't "sick enough" to have it, because that lands you in a cycle of deterring yourself from asking for help when you need to. Similarly, don't feel guilty because you are ill and can pay for therapy.
Shop around for someone who works for you
Therapists are people, and people can be irritating. It's probably not imperative that you actively like your therapist – unless your relationship is extremely unprofessional, you're not about to invite them for birthday pints – but you do have to find them agreeable and, more importantly, like their approach.
Some therapists are outwardly empathetic. I had one who was such a genuinely kind man that he'd run well over the hour I was supposed to be there, often into two or three, and recommend fiction and TV shows he knew I'd like. Going to his house was a bit like paying to visit your grandad, but with more existential chat. I'd wait until I'd walked around the corner after a session, as he waved me off from his doorstep, and burst into tears because he was nice to me, an uncomfortable reminder that I wasn't being very nice to myself.
Others are clinical and hard and let you project whatever you want onto their response to you. You sit, deflated, in the crease of their sofa, snotty-nosed and chest heaving with sobs after recalling visceral details of a trauma, and their face is like a mirror. You almost want to say, "Excuse me, did you hear the miserable thing I just said?" Neither approach is wrong, per se, as long as you respond well and feel comfortable with it. I, perversely, have come to enjoy the latter.
"When my therapist tells me they're going on a three-week cruise the week before they leave, I'll be outraged, thinking, 'How selfish. What do you expect me to do now? Look after myself?'"
If you're private, you're allowed to ditch them or cheat on them by testing out someone else behind their back. Don't buy into that stupid British attitude of sticking a commitment out because you've picked one now, haven't you, mate, and it'd be a tiny bit awkward to say it's not working. This is even more important if you've managed to access NHS treatment. If the person giving you CBT is a trainee and only reading off a print-out, shrugging helplessly when you ask personalised questions (this happened to me twice), tell your GP or them that you need someone else. You better believe that ten-week course will come to an abrupt end, so you deserve to get the most from it.
This desire for change can happen at any point, and I've learnt that a therapist who helps you work through one "issue" successfully might not be the best person to shed light on another. After a significant relationship ended I knew there was some sex and sexuality grey matter that I wanted untangling, and I quickly realised that the straight male therapist I'd been with for a while – who actually had a specialism in relationships – wasn't grasping the true essence of what I was saying when it related to being a young woman and my interactions with men. I ghosted him by never arranging the next meeting, because I couldn't face saying goodbye. I handled it like an utter child, but the move was the right thing to do; I quickly found a female therapist who could bring a shared history to the discussion.
You'll want them to like you – get over this quickly
It's in our nature to want people to like us. If you too are a people pleaser who responds disgustingly well to any form of praise, then watch out for this one.
Sometimes, when I'm telling my current therapist a story, without realising I'm doing it I'll find myself pausing for dramatic effect, or using my hands – the only possible motive being that I want to entertain her. If I get a laugh, it's a personal gain: my content is agreeable. Similarly, if I'm having a good patch of mental health, on the way to her house, after feeling grateful for relative wellbeing, I genuinely worry about boring her. I'll rake through my short-term memory because, at the very least, there's always something ridiculous I've done to make conversation about.
But just as you don't have to like them, they don't have to like you. If you don't fight this it'll change the way in which you work with them, and you're less likely to make breakthroughs. Therapists are there to aid you, not to be entertained, and just because you're the one sharing the grisly details, any power imbalance is imagined.
Don't hold back on the dirt
With the above in mind, be honest. Horribly honest. It's taken me years to stop withholding information, and I'm certain I've done it every time I start with a new therapist: "If I tell them this, they'll think I'm a slut, or a bad person, or an idiot." Part of this might be the age gap – my therapists have always been older than me – and part of it is probably because it can be incredibly unpleasant and uncomfortable sharing certain things.
But what's the point in holding back? Your therapist has likely heard worse than whatever you're going to come out with, and they can't help you as fully if you're repressing truth. My least favourite part of therapy is the fact that someone isn't conveniently telling you everything you need to know. Often you're the one coming up with the grand realisations, so all that talking about the horrible stuff is a process of being honest with yourself. Get to the stage of being able to admit whatever "it" is, and treat the therapist as an extension of yourself.
Communicate early on what you want to get out of it
The quickest I've ever felt like something was resolved with a therapist was when I swapped to a woman to talk about sex. I'd identified with grim precision what my problems were, where I suspected the knots had come from, and that I wanted them to dissolve in order to have some hope of a healthy relationship in the future. I walked into her living room on the first session like a boring bastard from senior management, with targets and lists, and after delivering my pitch she just raised her eyebrows and said, "Wow." It seems obvious, but the easier you make their job, the quicker they're able to get to the root of what's going on. If you're even a fraction as anal as me, you'll be calmed simply by the veneer of order that a plan and goals provide. Even repeating the plan over and over to yourself like a mantra if you're very ill is something I've found helpful.
On communication: if, with NHS treatment, you have come to the end of your course and haven't improved or reached your goal, communicate firmly a need for more, or for a course of increased intensity. If you get discharged and have to go back through your GP, the weeks or months of referrals and waiting stack up.
You won't remember what they said that helped, or at least the nuances, and grasping at it after the session will be impossible
In the lead-up to lightbulb moments with your therapist, you're offering little bits, they're offering little bits, and suddenly they hit you with a beautiful explanation that comes like a blow to your gut – you feel parts deep inside shift to meet up mechanically. Everything makes sense: your brain – you life! – will finally be better! As soon as you've left, try to remember what was said. You can't. It's slippery, the gold is gone. It's beyond infuriating, and endlessly mystifying.
This happened earlier this year when I was trying to get to the bottom of my anxiety around commitment and self-sabotaging of relationships. We were digging through the long period when my parents had to stay under one roof with us after separating – how cliché, how dull – for years, due to money, and everyone tiptoed around the house. I, meanwhile, was having monthly struggles with PMDD, and was suicidal, seeing a child psychologist.
My therapist kept asking me earnest hypothetical things you'd imagine a therapist to ask, like, "Imagine you went to find your mum to tell her a problem – where was she in the house? How would she respond?" and "How does that make Younger You feel? What do you then do after feeling ignored?" She then dragged out some scarily accurate analysis about me feeling like being a singular unit is the safest and only viable option, especially for when I'm struggling with my mental health, because relationships are temporal, depressing and dangerous to get tied into. That written down looks obvious, nothing, bullshit. But the way she said it, at the time, shattered me.
I'll always write some notes when I leave to try to capture some of it. But often, you have to accept that whatever it was that made perfect sense is now just a nugget nestled somewhere in your subconscious. The reason it seems so poignant at the time is usually just because it's the first time you've heard it – but you're now another step along, whether you realise it or not.
Recognise that your therapist shouldn't be telling you what to do, only advising
I had a therapist who told me repeatedly to make this big life decision. I ended up making the change, but I'm still acutely aware that I only did it because I was told to. There was no major threat to my health or life. Therapists are there to advise, to suggest and to guide; never let them take you to a place you don't like. Every move you make regarding how your life affects your mental health is – and should remain – within your control.
You relationships with other people will change
After ten years of this, I have no idea whether I was this much of a over-sharer to start with, or whether the fact I'm so used to splurging everything that now, like a cow edging into its stall to be milked, it just automatically happens. I'm ridiculously shameless in real life. It's very hard to embarrass me. Nothing that happens to me in real life can be worse than what happens in that room on a weekly basis, and this carries over to relationships. Therapy has improved my relationships with people more than I can quantify. I'll talk to a stranger in the street about anything. I have brilliantly honest friendships, where both sides know we can talk about anything; but because I'm only ever days away from talking about my mental health, I don't feel the need to bang on about it unless I'm really struggling. If anything, it's the last thing I want to speak about. Male friends like that I can be an armchair psychologist for them when they don't feel comfortable talking to other mates. People I date or are in a relationship with love it because I can use my session to consider any problems that crop up between us. It's like couples therapy, without them having to pay or show up.
"I always suspect therapists get curious and do a internet search of me. They're as human as the rest of us. I'd do it. I'd 100 percent do it."
Do the homework, even it seems futile
Broadly speaking, psychotherapy asks why you're thinking the bad thought, while CBT asks how you can manage, cope with or change the bad thought. I don't like CBT. Some mental health advocates would probably tell me off for saying that, but I don't think it should be treated as the anxiety and depression cure-all it's sometimes touted as. Mind you, I didn't help myself much the first time I did it.
A lot of the treatment involves doing the Year 7-type homework you're given, and I felt mildly ridiculous about ticking boxes and filling in columns and charts when I couldn't even type on my laptop without shaking. I remember resisting the process because charting how my thoughts transform into feelings and back again felt patronising, futile and insulting to my dazzling intelligence and rich emotional makeup. Eventually, I stopped being arrogant and got desperate enough to do it, and it did help slightly.
The same goes for the things you discuss in psychotherapy. When you make a plan with your therapist to apologise to people you fucked over when you were manic, or to start going to bed, devices switched off, before 11PM now you're depressed, then do what you can – without beating yourself up about it – to follow through with even the smallest of steps.
You think they're spying on you
If I haven't come across as self-involved enough already, try this: I always suspect therapists get curious and google me. In my defence, a therapist once mentioned something I hadn't told him in conversation. I questioned it, and he said – like it was the most casual thing in the world – that he'd been on my Twitter. He'd carefully turned over my tweets about Tinder and therapy and shagging and hangovers in between clients. Every therapist has known what I've done for work. Now, when I write an article about sex or mental health, I think about them reading it and comparing the real me to internet me, maybe musing over their next paper on the subject of the psychology and peacocking of online selves. My therapist could be reading this right now. If so, I am actually available on Wednesday now, usual time.
You can't envisage your life without it
I have wondered whether therapy has become an expensive comfort blanket. When my therapist tells me they're going on a three-week cruise the week before they leave, I'll be outraged, thinking, "How selfish. What do you expect me to do now? Look after myself?" I've had people say, "Aren't you going to run out of things to talk about?" (I won't. Having a chronic illness and mental health doesn't end, and neither does my ability to talk bollocks.) I've said to myself on occasion, "This isn't actually nice, is it, leaving your 8AM appointment visibly distressed to rush into work without a break to process what's happened. We could do without this."
But why shouldn't I stay in therapy? I'm the most consistently well I can remember being. Some people stay on meds their entire life; I go on and off them. Why does it matter to anyone else how I budget my money or manage my health? Over the past decade, I've briefly stopped a few times – due to the NHS halting my treatment when they shouldn't have, or because I felt I didn't need it anymore – and, every time, had a bad dip. By the time I'd scrambled to get a therapist again, or reconnected with my old one, I'd got a lot worse and taken longer to reintegrate.
My biggest fear is that true madness is around the corner; the sort of severe illness from which there is no return. I know it's possible for me to lose touch with reality, to create things that aren't there. There's no forgetting that fact. So if absolutely nothing else, I'm paying for a professional who knows what they're talking about to reaffirm to me, "You are a normal human being and you are not 'sick'" every week.
There's a chance that one day I'll do something else besides therapy. But if that never happens, I'm comfortable with the idea of 20, 30 or 40 more years of talking about myself.