I’m a 25-year-old queer woman who has struggled with anxiety in some form or another for most of my life. I’ve never been diagnosed but I’ve had what I think are panic attacks in the past, but I don’t know if they’re really bad enough to count; I have a friend with social anxiety and my panic attacks don’t sound as bad as his. I’ve wanted to start therapy for a while, but I don’t know what to look for in a therapist, and no one in my family has ever seen a therapist before. Where do I even start?
The first thing that I notice about your letter is that there’s a certain amount of doubting yourself and your experience. You say you’ve experienced anxiety most of your life, and in the next sentence, you make sure to write that you’ve never been diagnosed, and that you don’t know if your panic attacks are “bad enough” to be considered real panic attacks, especially compared to your friend’s. It is of course impossible for me to diagnose you from a short letter, but I do want to point out that whether the anxiety you experience fits into the definition of “diagnosable” or not, it has been bothering you badly enough and for long enough, that you’re writing in about. You don’t need to compare yourself to some objective experience of anxiety, and you also don’t need to have it “as bad” as someone else to be deserving of help and care. And while I understand the impulse to hold space for people who have it “worse” than you, you can also acknowledge and seek help for your own suffering without checking yourself (ESPECIALLY in therapy) or invalidating your experience. (It’s a practice, though, giving yourself the space and consideration you extend to others, and it’s understandable if it doesn’t happen overnight.) So here is your permission to declare your anxiety exactly as bad as you feel it, without the parameters of “bad enough,” from this therapist-in-training, to you.
As the first person in my family who has ever sought the help of a therapist, I relate a lot to your letter. Unfortunately, the process of finding a therapist is kind of like finding a good gynecologist — sometimes it’s hit or miss, and it can be really uncomfortable and awkward when you’re working with someone who isn’t a good fit. The first place I would start would be to ask around your friend group, if you have any friends who go to therapy. Ask them what the experience of therapy is like for them, how it felt in the beginning, how they found their therapist, what they like about the process, and what they don’t like. If you’re in school, you could also look into mental health services on campus and try out short term counseling there, or at least ask for local referrals. If you’re not part of any university, you could also look into community mental health centers, which have the added benefit of being more likely to accept insurance or offer sliding scale therapy options.
When I started therapy, I asked a friend of mine where she went, and she referred me to a clinic where interns were trained, which is also a good way to try to keep therapy costs low, if that’s a concern. I stayed with my first therapist for a couple of months, then stopped when her internship came to an end, and restarted again a few months later with someone new, who I still continue to see three years later. I had a pretty lucky, straight forwards process — the one person I saw in-between my former and current therapist was too expensive for me, but referred me to my current dude, and it ended up being a very comfortable working relationship.
While I hate “consumer” language when it comes to therapy (my supervisor refuses to refer to clients as “clients,” preferring the term “patients” because the root of the word — pathos — implies the suffering that therapy clients seek help with), there is some use in really taking ownership of the fact that this working relationship is about YOU and your needs. Any therapist worth her salt won’t force her own methods on you, choosing instead to gently stay where you are and take things at your pace, especially in the beginning of your work together. It’s important to pay attention to your first impressions and how you feel when meeting therapists to evaluate if you’re a good fit. Maybe jot down how you feel afterwards, without censoring yourself. It’s okay to give someone a couple of tries, but don’t feel like you have to doubt your gut feelings about someone. If you get a bad or uncomfortable vibe from someone, it’s okay to politely decline working with them, and keep looking.
When it comes to the type of therapy you think you would most benefit from, it’s also important to do your research. In my Masters program, we focus on two main schools of therapy – psychodynamic therapy, which originated with Freud’s psychoanalysis, and cognitive behavioral therapy, which was created by Albert Ellis and Aaron Beck. Psychodynamic therapy is known as insight oriented therapy; sessions are more likely to be open ended, and you’ll likely talk about your childhood, your family relationships, and your own relationship history as a means of making sense of what is troubling you now. Cognitive behavioral therapy, by contrast, is more geared toward helping you figure out how to solve problems and feel better now. There are a couple of different school of cognitive behavioral therapy, including ACT (acceptance and commitment therapy), DBT (dialectical behavioral therapy, created by Marsha Linehan in order to work with clients with borderline personality disorder), and REBT (rational emotive behavioral therapy).
I’m partial to cognitive behavioral therapy myself, because it’s clear and directive – you’ll come in each week with an agenda for treatment, and your therapist will give you exercises and homework to practice outside of session. The whole point of CBT really demystifies therapy and makes the client a part of the process, as opposed to psychodynamic therapy, wherein the therapist is still often treated as the “expert” or authority in the room. Cognitive behavioral therapies also tend to be more short term (10-12 sessions, though they can go on for longer) and more likely to be accepted by insurance companies, as they are more easily measurable (and god knows insurance companies are all about deliverable results).
There are yet more therapies available to you. Some of the types of therapies I’m into also include narrative therapy, where the client is encouraged to understand the story they are creating around their lives, and see themselves as separate from their problems, distancing themselves from the issues at hand and allowing for more agency and creativity in approaching stress and conflict. I find somatic therapy really cool, especially considering how often talk therapy seems to forget that we’re not just talking brains in jars, we have bodies that experience the world in non-verbal ways and receive tons of important information from the world around us. I also highly recommend therapies that encourage mindfulness – focusing on being fully present and embodied in the here and now – such as mindfulness based stress reduction, which have been shown to be effective with anxiety, depression, and even chronic pain.
If this all sounds overwhelming, don’t be alarmed! Most therapists in the U.S. at least practice from an eclectic, integrative perspective, and social workers in particularly receive a generalist education in their Masters programs, though many go on the specialize in a specific modality that resonates most with them. What this means is that you don’t need to know everything there is to know about the different types of therapy for you – you just have to have a sense of what might work for you. After that, you and your therapist can work together to uncover or create a specific approach that is unique to your needs, and they’ll bring the clinical knowledge and training. If you feel like you know what you want to come in with each week, or if you want to spend time exploring how your past led you to where you are today, the free association of psychodynamic therapy could work for you. If, by contrast, you want your therapist to be a little more directive, and you want to do homework assignments in-between sessions, maybe do a little exploring into the cognitive behavioral therapies. If you don’t know at all what might work for you, then that too is a perfect place to start with your therapist. Psychoeducation, or teaching clients the ins and outs of what they expect from therapy, is a big part of the beginning of the process, and most therapists are sensitive to the fact that many people come to therapy without knowing quite what to expect.
It’s also important to remember that when you show up to therapy, you bring all of yourself. That means that all the intersections of your identity – your race, your gender, your sexuality, etc. – are in the room with you. And the same is true of your therapist. While most therapists are encouraged to be conscious of this in the room with the client (and relational cultural feminist therapy specifically centers this in how therapy is practice), the unfortunate truth is that it is sometimes hard for folx of various marginalized identities to find good therapists. There’s no easy way around this, but remember that you deserve the type of care where you can show up with all of yourself. You shouldn’t have to spend the valuable time in therapy that you are paying for educating your therapist on issues of race or sexuality, for example, and you shouldn’t be expected to sit through microaggressions and ignorance as part of your therapeutic work. It can be extremely difficult to speak up and assert yourself to someone who has a lot of fancy-lookin’ letters after their name – but I’m here to let you know that just because someone is super educated, doesn’t mean they know everything, and doesn’t mean that they’re the expert in your life and lived experience. You are.
Finally, remember that your therapist isn’t going to have a magical cure to all your problems (though I can say from experience that it is VERY tempting to pretend I have all the answers to everything in, as evidenced in me writing this column). Therapy is work that you do, with the support and guidance of your therapist. Take a look into what kind of style you might be interested in. Are you cool with sitting and sifting through your past as your therapist helps you develop insight into your patterns? Maybe consider a therapist whose orientation is psychodynamic. Would you rather a therapist who takes a more direct, assertive approach, giving you homework assignments and exercises to practice between sessions? That therapist might lean more towards cognitive behavioral therapy, or any of its offshoots (I’m a fan of ACT). Are you artistic, creative? Art therapy and narrative therapy can be helpful ways to tap into the strengths of that side of yourself. Most therapists blend their approach and will adjust to your needs, but going in with an idea of what might resonate with you could help you narrow down your search.
Most importantly, remember that ideally, therapy is your place to be all about YOU. It’s your place to be safe, vulnerable, and authentic, in order for you learn about yourself. So start your therapy journey with that in mind, because it’s never too early to start practicing how to prioritize yourself and your needs.
Social media is your friend when exploring therapy for the first time. Check out these awesome therapists/collectives dedicated to doing the work from an intersectional perspective: