What to expect when you go to therapy for the first time

Congratulations! You have decided that you are ready to make major changes to your
life and your mental and emotional wellbeing. This is the first step to a truly bountiful life where you have peace of mind and self-awareness. I know that this is a strange
experience and that you are likely to experience a flood of different and often conflicting emotions about sharing intimate details of your life with a stranger, so the courage you have demonstrated must be acknowledged.

Very often, people feel nervous about what they can and cannot tell their therapists for
fear of judgement and consequences for past behaviour. All therapists are held to the
same ethical standards globally. We cannot disclose anything you say to us to anyone
else and that confidentiality is eternal. That means that even if you or your therapist
dies, no one can know what you told us. There are only three exceptions to this and
they exist for very good reasons.

1. You disclose the abuse of a child (and in some cases a vulnerable adult)

This is because vulnerable people in society need protection. If you tell us that
you are aware of child abuse, we have a legal and ethical obligation to inform law
enforcement so that the person in need of protection can have an intervention to
secure them. Your therapist will remind you of our ethics code when you start
therapy with us. You will be able to ask us questions about it which we
encourage.

2. You tell us that you plan to harm or kill yourself or someone else.

We certainly do not want you trying to kill yourself or someone else so, we have
to step in to stop you from these dangerous behaviours. However, we need to
make it very clear that we can only report on harm that is imminent. That means
that even if you harmed or killed someone on the way to your therapy
appointment, we cannot report on that because the act has already occurred. If
you tell us you plan to harm or kill another person at a point in the future, that is
when the duty to warn is activated and your therapist has to intervene to stop you
from committing a crime against someone else.

3. The court has subpoenaed our records

If you have a court case pending, the court does have the power to tell us we
have to either appear in court or allow the court access to our records. We are
legally compelled to do so or face legal consequences ourselves. However, case
notes are not written the way you encounter them on TV shows. They are
actually quite vague so that there is nothing incriminating about you in them.
Also, we often prepare documents for court so that you are not incriminated by
the things we record during our sessions. We learn how to do this in school
specifically for this reason so, please do not worry about our records.


Your therapist should go over confidentiality and its limits with you either at your
consultation (if the therapist provides these), or the first session. You will have the
chance to ask questions for clarification and discuss what this means with your
therapist. You are also asked to sign a consent form for therapy which usually includes
these three limits to confidentiality. Your signature tells the therapist that you are willing
to participate in the process of therapy until you decide otherwise. There is usually a
statement to let you know that consent is ongoing and that you can revoke consent to
therapy at any time. This means that you can always decide that the fit between you
and the therapist is not working for you and that you would like to end the relationship
which your therapist will understand.

Different therapists work using different approaches to therapy. There are many, many
types of therapy but what we do know from all the research done on the effectiveness of therapy is that it does not really matter what approach your therapist takes to working with you, it is the relationship between the therapist and client that best predicts whether or not the client will improve. This is why it is very important to be honest both with yourself and your therapist as to whether or not you feel supported and understood. Your therapist is there to help you speak up for your own needs and very often, we welcome your honesty. Ultimately, you are the person in charge of how much or how little you give to the therapy process. If your therapist suggests you try something in a session that is not working for you, please do not feel coerced into trying it anyway. There are thousands of interventions we can use with you and through collaboration with you, we are usually able to find something that is more in alignment with your personality and values.

One of the comments that therapists hear very often is “why do I need to pay someone to give me advice when I can just talk to my friends and family?” This is a common feeling in our society where there has been an understandable lack of trust in people with perceived power. Firstly, therapists do not “give advice”. The key difference between your social circle and your therapist is that we are trained to listen to you and help you tap into strengths you have without judgement. We also are able to ask you critical questions that help you think about things differently in a manner that your social group cannot because they lack the training and they are also close to you and therefore, are generally incapable of impartiality. This is why therapists, like doctors, cannot provide therapy to our own social circle.

As you enter therapy, know that the process is likely long and potentially painful at
times. Therapy encourages you to dig deep into your past, your thoughts, your
childhood, patterns of behaviour and a host of other facets of your life that we often try
to avoid looking at. There will likely be tears, anger and frustration and, there will be
days when you want to quit. However, remember that patterns of behaviour develop
over years and that growth and change happen slowly so, do not be alarmed if you
attend one session and do not feel fantastic forever. In fact, it is at that point where you
feel hesitant to continue that we advise you to stick with the process as you are likely on the verge of a major shift in thinking, feeling and acting. This desire to quit right before this happens is so common that therapists expect it. Again, telling us how you feel is important for us to normalize this experience and educate you on what is happening for you and why.

It is indeed the hope of all therapists that you will find it transformative in working with
us. We do genuinely care about your progress and the therapeutic relationship we
develop with you is real. Those of us who are called to this profession, enter it out of a
genuine desire to help others to overcome the pain of their past or present so they can
show up differently in the world in the future. For this reason, we encourage you to keep talking openly to us so we can help you help yourself. The power to change truly lives within you and we are willing to walk alongside you as you embark on your journey towards your “best life”.

Psychiatrist vs Psychologist: A Rose by any Other Name or Something Different?

Recently, a friend of mine revealed that he needed some counselling support for a
family member and that he wondered about my reviews of a particular psychiatrist for
the person. Having had this conversation very often with random people, family and
friends and of course, clients, I felt the need to clarify a few things about the key
differences between the terms “Psychiatrist” and “Psychologist” in very simple terms.
Those key differences in job function will better help you to decide which professional is the more appropriate one for your needs. Both use the title “doctor” but, their ability to do so is based on stark differences.

On a very basic level, the major difference is that a psychiatrist is a medical doctor with additional training in psychology and psychopharmacology. Simply put, this person went to medical school and decided to specialize in the use of drugs to treat and manage severe clinical mental disorders. They would have completed a residency in a hospital or clinic setting where they address the concerns of people with chronic issues like mood disorders, personality disorders and other “diagnosable” conditions. They do provide “talk therapy” like psychologists and counsellors do, but they are able to prescribe drugs to help manage mental disorders and the scope of the work is different.

A psychologist, on the other hand, is someone who has completed a Doctorate in
psychology. Someone with a Masters degree in psychology in North America or the
The Caribbean, cannot call themselves a psychologist although in some other countries, a Masters is sufficient to qualify for the title given a certain number of years in practice. People with a Master’s in psychology in either clinical or counselling are called therapists, associate psychologists or counsellors and the difference between this group and a Psychologist is usually the ability to conduct professional assessments after more years of school. This field is focused on greater depth work with people who may or MAY NOT have a mental health diagnosis and require longer term work on patterns of behaviour, early childhood and family factors and a host of other longer-term features of their lives. They also work with people with non-diagnosable issues like relationship concerns, life transitions, grief and loss, family problems and a host of other human experiences. This means that one does not have to be considered “mentally ill” to see a psychologist.

For this reason, when people are trying to make a choice between the two, I often ask
what are the concerns they want to address? My question, although it feels nosy, is
based on the desire to determine if the person needs a medical model practitioner,
(psychiatrist), or a talk therapist (psychologist) or, if the person would benefit from
seeing both.

Seeing both would make sense if someone has a diagnosis of Post-Traumatic Stress
Disorder (PTSD) for example, after experiencing, witnessing or hearing about a
dangerous or life-threatening situation. Indeed, many people have experienced at least one traumatic event and would benefit from addressing it. People who have severe PTSD may initially benefit from anti-anxiety medication to help them stabilize long enough to do the deeper talk therapy. These prescriptions are administered by the psychiatrist and often the deeper work on the issue is done by the psychologist. Most counsellors and psychologists do specialized training in working with trauma and so they usually collaborate with psychiatrists to better care for the client. Often, as the person manages to go through the trauma counselling with the psychologist (or
counsellor), the psychiatrist can wean them off the drugs given to stabilize them. This is but one example of how these two related professions collaborate. However, there are many situations in which either one or the other is better suited to the individual’s needs.

When deciding whether or not to see a psychiatrist or a psychologist, there are a few
questions to ask yourself;

1. Do I think that I or the person for whom I am seeking support has a mental
disorder?

The answer to this question includes observing their behaviour to determine
whether or not their behaviours, thoughts and mood are negatively affecting their
lives. For example, if a person is acting impulsively and is spending money
recklessly, not sleeping, is talking rapidly and seems to believe in their
invincibility and creativity, this person may be exhibiting warning signs of a mood
disorder and would benefit from seeing a Psychiatrist first to have an assessment
done to potentially get a diagnosis.

2. Is there an issue between me and my romantic partner, child or another family
member?

Most relationships experience challenges at one point or another. Conflict is
inevitable but, not everyone has the ability to manage it effectively. Sometimes,
there are concerns about closeness in the relationship, there may have been
betrayal or some other inter-personal problem which is causing you to go into
therapy. Situations like this are better served by a Psychologist or a Counsellor
as both of these professionals has trained specifically to address these kinds of
dynamics. Should they suspect though, that there is a component of mental
illness operating in the relationship, they will often refer the client to a Psychiatrist
to see if drug therapy is necessary and will collaborate with the client’s
Psychiatrist to provide better care for them.

3. Have I been stuck in my life and afraid of changing careers, moving to another
country or city or trying to make sense of my feelings about retiring?

Life transitions are best handled by a psychologist or counsellor as these are
normal parts of life with which most of us struggle. The benefits of talk therapy
are usually enough to help you develop coping skills for your situation or to help
you figure out the ways in which your fears may be limiting your ability to live
your best life. There are also counsellors and psychologists who specialize in
career counselling to help you figure out the different career paths available for
you to capitalize on your strengths. This is the kind of work not done by
psychiatrists.

4. Am I having questions around my sexuality, gender identity or issues with sexual
activity?

This is definitely not the work of a psychiatrist. Counsellors and psychologists
who do this kind of work have to be specially trained in human sexuality and sex
therapy in order to be able to provide this kind of service. The same is true for
any work around your intimate relationships. Psychiatrists are NOT trained in
couples and family therapy.

Please make sure that you ask the person you approach specifically if they are
trained in these matters as this type of training is not standard in Masters and
Doctoral programmes. Psychiatrists are not equipped to do this type of work
either.

5. Is the service for someone who is a caregiver or family member of someone with
a mental illness or substance misuse problem?

People who support those who struggle with mental illness are better suited to
work with a psychologist or counsellor as their work is around stress
management, psychoeducation about the illness in question, self-care and
emotional support.

Even for those who struggle with substance misuse, psychologists and
counsellors are very effective in helping clients get to the root cause of why they
are misusing substances in the first place. Psychiatrists may be able to prescribe
drugs like Methodone or Suboxone to help those whose drugs of choice have
been opioids but generally the deeper work is done by psychologists and
counsellors given the fact that usually, trauma is the underlying reason people
engage in substance misuse.

6. Is the person someone with a developmental disorder like autism, fetal alcohol
syndrome or a learning challenge?

If the person is dealing with a developmental issue, there are psychologists and
counsellors who specialize in working with them. There are multiple types of
psychologists and counsellors who focus on different aspects of these concerns.
School counsellors and psychologists work with students and their families to
help manage the child’s ability to function at school. Counsellors who specialize
in working with children and adolescents help them with emotional regulation,
social skill development and better relationships with peers as well as to a lesser
degree, their parents. This type of work usually falls outside the scope of a
psychiatrist’s work unless the child in question also has a mental illness.

Hopefully, many of your questions regarding the differences between a psychiatrist and a psychologist have been answered now. When you are in doubt though, it is always a good idea to contact a counsellor or psychologist to help you figure out which professional is best suited for you or your friend or relative.

Finally, it is very important that you know that both professions are ethically required to
keep whatever you tell us confidential even when you have committed a crime in the
past and are coming into therapy to discuss its effects. There are only three situations in which we are expected to break confidentiality with you which are done to protect
vulnerable people. For example, if you report child abuse or neglect, we have to involve the necessary child protection agencies to keep the child or adolescent safe. The same is true if you report the intention to harm or kill someone and we have reason to believe that you are serious or, if you tell us you plan to harm or kill yourself. Finally, if the court subpoenas our records, we are legally required to prepare a report for legal proceedings. Apart from this, anything you say to us is kept in confidence even after one of us has died.

Psychologists, psychiatrists and counsellors do not judge you. Most of the things you
think are shameful, extraordinary or bizarre are things we are trained to handle and for
the most part, have probably heard some variation of this before. We are always more
concerned with what is best for you and we don’t talk to anyone else about what you
have said to us as we could lose our license to practice on account of that type of
unethical behaviour.

Ultimately, seeking support in times of distress is no indication of “insanity”. In the same way that you would visit your family doctor for a broken leg, migraines and all manner of other physical concerns, going to therapy are good for the mind and soul. It is time that we start to normalize talking to a trained professional about the problems we face as they are often able to help us in a confidential manner that our friends and family simply cannot. I would encourage everyone to act in their own best interest and try to access the help of a trained counsellor or psychologist so that you can create a life you do not need to escape from or endure.