Who Needs Therapy? Part 3: What to expect from therapy

In the final part of this series on psychotherapy, I will say a bit about what to expect from the process, and what is expected from you.  Despite the popular joke that everyone has a therapist, my experience is that most people who consult me are first timers, and have very little idea of what is involved, how it “works”, how long it will take, etc.  In point of fact, there are no uniform answers to any of these questions.  There are almost as many theoretical approaches and therapy techniques as there are individual practitioners.  Expanding upon a point I made in Part 2 of this series, it is important to pay attention to the “fit” between yourself and the therapist.  Do you feel comfortable airing intimate thoughts with this person?  Does the approach and methods s/he uses seem sensible and worthwhile to you?  Do you feel that s/he is listening carefully and respectfully to you?  Does he/she spend enough time getting to know and understand your situation before offering advice or interpretations?  Do you feel free to disagree with his or her suggestions and opinions?  Is s/he giving you enough time to reflect on your thoughts and feelings before commenting?  Conversely, do you feel as if s/he is simply sitting and listening without offering any useful feedback?  Considering all of these factors will increase the chances of building a successful “therapeutic alliance”, a factor which has been shown consistently by research to be a powerful predictor of effective psychotherapy.

When you arrive at your first therapy appointment, you should expect the therapist to inquire about the reasons for your visit and what you would hope to get from therapy.  If you are only looking to follow the Standards of Care requirements in order to get a letter for hormone therapy, do let the therapist know so that the agenda is clear.  If you have little interest in a deeper self-examination, I would like to know, so that we can narrow the focus to that which is necessary to accomplish your goal of receiving a referral. The same would be true if you were looking for a second opinion letter recommending surgery, which can usually be accomplished in one or two interviews.

If, on the other hand, you are looking to work with a therapist in a more exploratory way about gender identity, or you are seeking guidance in navigating transition or other options for increased gender comfort, or you need help in dealing with family conflicts arising from your transgender identity, then you will probably want to consider committing to a period of regular weekly therapy sessions, continuing for a period ranging from a few weeks to a few years, depending on your goals and the obstacles you are facing.

My own approach is to use the first 1-3 sessions as an extended intake period.  During that time, I will take a thorough history, including family, social, educational, relationship, health, vocational, sexual, and spiritual points of reference.  I will be particularly interested in things like early trauma and loss, personal and family psychiatric disorders or symptoms, and past and current relational/family patterns and functioning.  In order to understand you as fully as possible, I need to know as much as I can about your life up to this point.  Without this information, I would be approaching you blindly, as a generic case rather than a unique individual, and you can get that kind of therapy from a self-help book.  Throughout the intake process, we are building trust and the beginnings of a relationship, but it is still pretty one-sided, because I am asking a lot of questions.  Nonetheless, those questions may cause you to look at yourself and your issues differently.

Once the intake process is complete, your therapist will have conveyed to you some idea about what the emphasis should be in your therapy. Ideally, you and your therapist will define a few goals, and agree upon what achieving those goals might look like.  For example, you might want to have better self-esteem, and decide that one sign of this would be fewer self-critical statements in therapy and in your daily life.

A typical goal for a transgender person might be to accept and embrace him/herself as a transgender individual.  Inside and outside of the therapy room, your therapist will look to point out behaviors that might be indicative of internalized transphobia or, conversely, behaviors that reflect healthy self-acceptance.  Identifying examples of both the desired and unwanted thoughts and behaviors will allow you to be more conscious of the external and internal factors that trigger them.  Some self-negating behaviors can respond readily to cognitive behavioral techniques, but a more deeply ingrained failure of self-acceptance can be very difficult to treat with short-term approaches.

A major aspect of psychotherapy is that you are expected to be an active participant in your therapy, both in and out of the office.  Once you have defined your goals and have some idea of the problem areas in your life, you will need to be paying close attention to your inner and outer life for examples to work with in your session.  This is the best way to get the most out of your time and financial investment in therapy.  Your therapist is working from the material that you bring to the session, so if you find yourself sitting down and waiting for him/her to get the party started, you will be disappointed.  If you are the type of person who needs specific “homework assignments”, let your therapist know that you’d like something to be working on in the week to come.

Although you are expected to participate, a therapy office is not a classroom lesson or a corporate meeting.  Often, the most productive work in therapy can come when the client has no particular agenda, but is willing to talk freely and openly about what is on his/her mind.  When I see that this is the case, I encourage clients to sit with themselves and “see what comes up”.  Transgender folks, in particular, have often exerted years of psychic energy toward the goal of NOT hearing that “still small voice within” in order to avoid facing painful truths. Having permission to examine one’s own personal truth, whatever it may be, can be one of the most liberating outcomes of therapy exploration.

I’ve tried to touch upon some of the major questions people have about therapy in this three part series, “Who Needs Therapy?”  I welcome your questions and comments.  Next month, I will address the topic of the so-called transgender spectrum and how I go about exploring with therapy clients where they fall on this spectrum and what they might do with this information.  Until then, enjoy a danse de Mardi Gras with somebody you love as we count down the days until the arrival of Spring.

Category: Transgender Body & Soul