Getting Started in Psychotherapy: A Guide for Patients (and Their Therapists)

What patients and therapists both need to know.

Psychotherapy works best when patients understand what they’re supposed to do—how to use therapy effectively. It’s not intuitive, and there’s nothing to compare it to. Too often, in the rush to get started, explanations about what to do and expect are skipped. That’s not the best way to begin.

Research shows that the difference between success and failure often comes down to patients getting an explanation at the start. When they do—whether it comes from the therapist, a video, or a handout—they tend to keep appointments, stay in treatment, and work through challenges. They get the benefits they came for. That’s where this guide comes in—to set you up for success.

When I taught psychotherapy to psychology and psychiatry trainees, I created a patient handout to explain what to expect in psychotherapy. Some used it as a guide for conversations with new patients. Others gave it to patients to read, then discussed their questions. It’s helpful both ways.

It was the handout my trainees kept, shared with patients, and posted on their websites. Now I’m sharing it with you.

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Will my therapist give me advice?

People often assume a therapist’s job is to give advice. But advice isn’t psychotherapy. In the long run, it’s rarely helpful.

If advice were enough, you wouldn’t be coming to therapy. You can get advice anywhere—from friends, family, or the internet. Instead of advice, your therapist will help you see yourself and your situation more clearly so you can make choices that are right for you.

What do I do in therapy sessions?

Talk as openly as you can about whatever is on your mind, without editing or censoring yourself. This may sound easy, but it’s often incredibly difficult. Some thoughts will seem unimportant. Others may feel unpleasant, embarrassing, or inappropriate, including thoughts about your therapist. Say them anyway.

If you notice something is getting in the way of speaking openly, bring it up. Talk about what’s making it difficult.

Advice isn’t psychotherapy. If advice were enough, you wouldn’t be coming to therapy.

How will talking help me?

It can be hard to see how “just talking” will help, but talking is the heart of psychotherapy. As you talk, you come to know yourself better. You start to recognize patterns. New options and possibilities emerge. Research shows that most people benefit from therapy, even those with the most serious problems.

The benefits are not immediate. At first, there may be no obvious connection between what you are talking about and how your problems will improve. It’s like planting a tree. There’s no immediate connection between planting seeds and eating apples, but if you plant seeds and tend to them, apples will come.

If you start therapy intending to try it for a session or two just to see what happens, you’ll likely be disappointed. That’s like planting seeds, then deciding it’s pointless because there are no apples the next morning. Therapy takes time. Give it a chance to work.

Is therapy like talking to a friend?

It’s very different. With friends, you pick and choose what you talk about. In therapy, you try to say whatever comes to mind, without knowing in advance where your thoughts may lead.

Friends take turns sharing information. In therapy, you will do most of the talking. Your therapist will learn a great deal about you, but you’ll know much less about them.

Another difference is that your therapist cannot socialize or meet with you outside therapy appointments. They can’t meet you for coffee or accept social invitations. This has nothing to do with whether they’d enjoy seeing you. It’s because a therapist can’t have a social relationship with you and also be an effective therapist.

What if I’m unhappy with my therapist?

When you start therapy, you should feel you can talk to your therapist and that they are interested in you and able to understand you. If you don’t connect in the beginning, it’s wiser to choose someone else.

As therapy continues, there will be times when you feel upset, disappointed, or angry. This is normal. When it happens, it’s important to talk about what’s bothering you. This is not the time to skip sessions or quit. It’s the time to talk about it.

If you’ve been working comfortably together and suddenly find yourself feeling angry or wanting to quit, it may mean therapy has touched on something difficult and important. That’s often when the most valuable work happens.

Why stay if I’m angry?

At different times, you may have feelings toward your therapist similar to feelings you’ve had in other important relationships—including hurt, disappointment, fear, and anger.

Talking about these feelings is crucial. When you discuss your feelings toward your therapist, you’ll also be learning about yourself and your relationship patterns. This makes it possible to recognize and rework self-defeating patterns—so you don’t have to keep repeating them.

Meaningful psychotherapy stirs up strong feelings. This is when the important work happens.

A key difference between therapy and other relationships is that in therapy, you talk about your feelings instead of acting on them. For example, if you’re angry with someone else, you might avoid them or retaliate. If you’re physically attracted to someone else, you might act on the attraction. But in therapy, you talk about these feelings. This is how you gain self-awareness. Whatever feelings you have are okay; the important thing is to talk about them.

What about the unconscious?

You may have heard that psychotherapists are interested in the unconscious. There’s nothing mysterious about this. It simply means we don’t always know why we feel or act the way we do. Psychotherapy can help you understand.

For example, you may have found yourself feeling unreasonably angry with someone, out of proportion to the situation. This can happen when the person reminds you of someone else, and you don’t realize it.

In this example, understanding unconscious thoughts and feelings could be as simple as remembering why you’re angry and recognizing that the two people are different. Why does this matter? Because if you take your anger out on the wrong person, you can damage important relationships. If, for example, the relationship is with your life partner or boss, you may be in for a rough time.

Others may want you to quit

As therapy continues, people close to you may urge you to stop. This often means you’re changing, and the changes are confusing and troubling to them. They’re used to the old you and your familiar patterns. Sometimes they’ll think you’re getting worse just when you are starting to get better. Be prepared for this.

You may be tempted to skip sessions

There will likely be times you struggle to keep appointments. You may have work demands, family responsibilities, or other obligations. They’ll seem unrelated to therapy. But they often come up just when therapy touches on something difficult.

This is when you’ll do some of your most important work. Don’t judge beforehand how important a session will be. Resolve to keep every appointment, no matter what.

Ending is part of therapy

At some point, you will start to think about ending therapy—ideally because you’ve accomplished what you came for and life is on a better course. But don’t rush. Ending is an important phase of therapy, and you need time to talk about it.

Let your therapist know well in advance that you’re thinking about ending. When the time comes, agree on a date for your last session—then plan to do meaningful work in the time leading up to it. Expect things to come up that haven’t come up before. Plan to use the time to consolidate your gains, take stock of what you’ve accomplished and what’s unfinished, and consider together what lies ahead. Don’t miss out by ending abruptly.

Ask questions

This guide covers some basics that are helpful to know when you start therapy. You may have many more questions. Ask your therapist about anything you don’t understand.

Sometimes your therapist may want to explore the thoughts and feelings behind your question instead of just answering it, so the two of you can learn more about how your mind works. But don’t hesitate to ask.

Psychotherapy is not something done to you, like a medical procedure. It’s a collaboration and a partnership. What you put in shapes what you get out.

Portions of this document were adapted from Luborsky, L. (1984), Principles of Psychoanalytic Psychotherapy. Basic Books.

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