First session with therapist - help!

I *may* have finally found a way forward with therapy. Basically, I am in the UK and although my psychiatrist, GP, the crisis team and anyone else I have spoken to agree that I need some sort of talking therapy, the only thing available via the NHS is yet another course of CBT which failed miserably the last time I tried it.
So, I was directed to a local scheme that offers low cost therapy, and they put me in touch with t therapist who I am meeting for the first time on Saturday - and now I am terrified.
I have no idea what to expect, all I know about her is that she is female, and on her (highly uninformative) website she says she does psychodynamic therapy and CBT.

So, any help appreciated, anything I should ask specifically, things I should look out for, or just any encouragement. I have really bad social anxiety and so meeting someone new is a bit of an ordeal (especially as I will also have to talk about myself).
Plus, I am rapidly running out of options and so if this doesn't work out I have no idea what I will do...

Ugh, I hate CBT.

I don't have any advice on things to look out for or ask. I tend to just take things as they come. Oh, if you have never worked with a psychodynamic therapist before, prepare yourself for the resounding and frequent silences. Psychodynamic therapists love that ****.

Just read this, LittleBlackDog, and wanted to respond.

Because this is a new encounter, as you point out, all of your defenses will be up. I say , PAY ATTENTION TO THEM. Set aside your concerns about the future, your lack of options therein, etc, and give out as little as possible about yourself. It's just an introductory session, so you shouldn't need to lay out the entire trauma of your life.

APPROACH WITH CAUTION! You will need to be evaluating this new person with all of your antennae, and ask yourself when the appt is over, just how you feel. Do you feel, overall, OK with going back to another session? Let us devoutly hope so.

If not.....

I'm not entirely sure what psychodynamic therapy is, and I know what CBT is, but I didn't have a good experience with it, myself, personally. I don't really have any advise. Like Susannahsays, I tend to take things as they come also but I just wanted to send you HUGS and let you know you aren't alone. First sessions are hard. HUGS Kit

Oh joy - the awkward silence, my favourite. I also hate CBT, which may not be the best start with someone who lists this as one of her two therapy tools...

Thank you. I do feel under pressure to somehow make this work as this is the only therapist in my area who is prepared to offer low cost therapy, and beggars can't be choosers. But, this is (whats left of) my mental health and I know that it will do me more harm in the long run to work with the wrong person/wrong modality.

Thanks.

I am really trying not to mock you at all with my response, especially because the more cynical side of me embraces the feelings and the hilarious way you put this.

But my longterm T-- I've seen him for 10 years-- is very eclectic rather than a straight purveyor of CBT and Psychodynamic theory. He uses both from time to time. There is a piece of CBT that allows you to consider how you look at something and whether or not there's another, more benign way to see things. Especially if you have a tendency to react strongly to things other people say and do and question their motives and intentions. I think CBT can be helpful in reframing core beliefs and challenging yourself to see who you are in a more realistic light, too. And my approach to my T's long silences was just to tell him I didn't like them, and he has been flawless for many years in jumping in. So it's possible to teach these therapist people how to work with you.

Keeping an open mind and being willing to ask for what you need goes a long way in making therapy work, at least in my experience. Rigidity and knee jerk reactions usually don't work out so well for me.

My therapist used combinations of behavioral (CBT/RBT) and psychodynamic. It was actually the most effective work I ever did with a therapist. These two approaches can work hand-in-hand with each other quite well. I think it's probably a positive that this therapist list both approaches and isn't only CBT or only psychodynamic. Keep an open mind and see how it goes. Honestly, my therapists NEVER talked about what therapy approach they were using, but in retrospect, it was apparent.

I'm more talking about formal/official CBT. Seems to me that all types of therapy incorporate stuff that challenges beliefs, and I don't have a problem with that. CBT is what I find to be rigid in its manualized approach. I just don't find it useful. I am already a very logical person and one of my main issues is undervaluing emotions - both in myself and others. CBT really just reinforces the lack of balance already in place due to my personality. I also just have an issue with CBT being used to treat depression. Depression can cause a lot of doom and gloom irrational thoughts, and I really have an issue with the assumption that the thoughts are always what causes the depression, instead of the other way around. I think CBT can actually be downright harmful in this respect.

Anyway, I don't think it's rigid or not being open minded not to like a specific modality. I was flippant in my comment about psychodynamic therapy, but that is the modality that the therapist I see practices, and I am not against it. Finally, I'm not sure if you were suggesting that I have a knee jerk reaction to CBT, but if so, that assumption is incorrect. My opinion on straight CBT has taken time to form and is based on issues I have with its theory as well as its implementation.

I had two therapists that used psychodynamic modality (one doing only that, the other more eclectic) and I never had silences in my therapy. I personally can't imagine just sitting there staring at the T or the wall and paying for it.

OP, you didn't say what specifically you seek therapy for, is it anxiety? I think that's one area where CBT can actually be quite productive (especially when the anxiety is specific, like social anxiety or phobias), but I believe only if the client complies with the approach and practices it. I do agree with the above that using it for depression is trickier and probably less effective as depression is really not a cognitive distortion.

I have severe depression, generalised anxiety and social anxiety. I am treatment resistant (have tried so many drugs/combinations of drugs and none of them work).
I have had CBT in the past, when I was first diagnosed with depression and it made me much worse. I have several issues with CBT, the main ones being that it is too simplistic and doesn't take past experiences into account (and how they may have shaped my beliefs about myself). The main problem was that it forced me, for the first time, to put these core beliefs into words but then I wasn't able to challenge them. As an intellectual exercise I can reframe things, but I just can't make myself believe them and so just ended up feeling worse.

I will go in with an open mind, and I am willing to revisit some of the CBT work. I guess it is all unknown at the moment, which is partly what is making me anxious...

That sounds a bit concerning... I do believe that bad therapy can be worse than no therapy. Have you tried some of the more experimental methods for treatment-resistant depression such as brain stimulation or ECT? I consider myself a quite rational person and have never suffered with very severe and stubborn depression, but even with the milder one I experienced, I could not think myself out of it or change the symptoms with mere cognitive exercises. Maybe start with the most specific part and work on that first, such as the social anxiety. See if the CBT helps that and if it does, try to use the learned methods for the other components.

I have never done CBT with a therapist but used some elements on my own for specific forms of anxiety, issues with motivation and impulse control. It never made the anxiety and the impulses (the feelings) go away but did help regulate how I react to my symptoms.

I found cbt to actually be damaging. It did not help with anxiety or depression for me. I am not saying it never helps some people -but it is the one type that I found not just useless but actively harmful.

Not sure what your experience was but one way it can definitely be harmful is when someone is really being forced to believe that the symptoms are just things we make up with our minds. I think it can damage a person's self-esteem (which is usually not very high in depression to start with) to believe one should be able to control these states consciously and if it does not work, that one is not doing it right / not open to it. This is why I said I would focus on how I react to my symptoms and see if I can change behavior against the emotional current instead of expecting it to eliminate the feelings.

No I haven't. TMS is not offered where I live. I was offered ECT (and my previous psychiatrist really pushed me to agree to it, but I am not convinced of its efficacy, the relapse rate is high and I was very concerned about cognitive side-effects and more concerned that my concerns were completely brushed off by the psychiatrist.

I can see how CBT could be useful for some people in some circumstances but it wasn't for me. what made it worse was that, having gotten worse, I was then discharged by the therapy team with no further support (because they don't offer any alternatives) which made it even more difficult.

My therapist is psychodynamic/psychoanalytic and though it is a longer process I think it is helpful. Really it is just a lot of talking and trying to see patterns, understand the obstacles and look for ways to grow. First sessions usually involve a more formal Q & A with the T asking about your history, family situation, etc. and maybe thinking about what your goals are, in terms of what would improvement look like to you, what are you hoping to get out of therapy.

I would agree with those who say to try to keep an open mind and see how it goes. Good luck.

Maybe try just one or two sessions and see if any of it makes sense with the new therapist. And leave if you can't see it being helpful. CBT is meant to be relatively short-term anyway so it's not like other forms of long-term therapy, where they often claim you need to take a leap of faith and trust that there will be some helpful process eventually. If you often avoid people due to social anxiety and depression, perhaps even just talking to someone and having a routine (weekly sessions) that draws you out regularly for a while could be helpful? I did not find therapy very useful either but there was a time when I really struggled with motivation and that one aspect, preparing for my sessions and going out often at times when I would not want to get out, was somewhat helpful. What it achieved was experiencing and reinforcing the fact that sometimes it is better to act and do things completely against my desires (or lack of desires) and my motivation increased even just by forcing myself to overcome the force to avoid things, the act of overcoming turned out quite rewarding and then I felt like tackling other issues as well.

One thing I really don't like about the CBT approach is forcing to artificially separate thoughts and feelings. Sure, it can be useful to separate them for the sake of analyzing them, but they never really function separately or in a sequential, linear manner in the mind. What can be more helpful, for me at least, is to separate thoughts/feelings and behavior. That's what I said above about acting constructively in spite of no motivation and negative feelings/beliefs. It can be very hard but even just going through the motions repeatedly can sometimes generate reinforcement to be proactive and learn how to function better with chronic depression and anxiety. If the latter is achieved, I would consider the therapy successful in some ways, even if it is not exactly what they expect and push with it.

Good luck littleblackdog! I am glad to hear you were able to find the sliding scale therapy and you never know...you just might score a good one...

Let us know how it goes.

FearLess47

This is curious to me as not filling silences is a hallmark of psychodynamic therapy. Of course, the client can always fill the silence, but the psychodynamic view of silence is that it is a time for reflection and insight. This book, Psychodynamic Therapy Techniques, lists silence as a "foundational psychodynamic technique" (and provides several pages of explanation if you are interested). I doubt your two therapists were strongly oriented to psychodynamic therapy if silence was never something they employed. The linked book also outlines when silence is contraindicated and a therapist should break the silence. Maybe some of them apply to you.

Someone on reddit recently described their therapist's use of silence as "the silent treatment." I plan on deploying this characterization at the therapist soon. I wonder what she will say.

Yes I am familiar with silence being part of the approach, I just never experienced it because I was never silent longer thank a few seconds when I was thinking something or when I was listening to the therapist. It never occurred to me to do more and would have found that awkward. My psychoanalyst originally was interacting much less and I told him I wanted him to contribute more, otherwise why do I pay him. He then did and there pretty much all of my sessions were conversations. I know he uses silence as a tool as he talks about it in online media, just not with me as I did not allow it.

My point is that what you're describing doesn't sound like a psychodynamic approach. Becoming more interactive at the request of the client (because they don't want to pay to sit like a bump on a log) makes it something else. It's like if you were in psychoanalysis and told the analyst that you didn't want to do free association. The resulting therapy could draw on psychoanalytic principles, but it would not be psychoanalysis. Although for the record, I don't see anything wrong with modifications. The silence is awkward. I wish the one I see didn't do it so much, but she is very resistant.