What You Should Know When You Start Psychotherapy

An information leaflet outlining professional standards, patient rights, and possible risks in psychotherapy.

Photo by Marcel Strauß on Unsplash

Introduction

Starting psychotherapy is not easy. It requires acknowledging the need for professional help, overcoming fears and stigma, finding a therapist, who is available, and navigating a fragmented landscape of methods and approaches. Financial constraints are common, including concerns about insurance coverage and affordability. Managing all that is no small feat.

By the time people arrive for their first session, they may find themselves sitting across from a psychotherapist feeling a mixture of anxiety, hope, and uncertainty. Understandably, many patients in this situation are unsure what questions to ask, what information matters, and what their rights are.

Fortunately, there are clear answers to many of those uncertainties. That’s why I wrote this article: to educate you, the reader, on what you should know and look for when starting therapy¹.

Before You Begin

You should be the one to decide to start therapy. It’s important that you feel comfortable with your therapist and understand their approach. During the initial session, you will be asked to describe why you are seeking therapy, what you hope to change, and what you expect from the process.

Clarify practical matters with your therapist, such as session frequency, fees, cancellation rules, and initial therapeutic goals. These agreements form what is often referred to as a therapeutic contract. While it does not need to be formal or written, it should be clear enough that both parties know what they are working toward and the conditions under which they are working.

Transparency and honest communication are essential for establishing a strong therapeutic relationship and forming the foundation of effective therapy.

What Psychotherapy Is

Psychotherapy is an effective clinical treatment that is used to address psychological suffering, mental disorders, and psychosomatic complaints. It is used when relational, emotional, cognitive, or behavioral difficulties persist over time, interfere with daily functioning, and cannot be adequately managed with personal coping strategies or social support alone.

There is no one-size-fits-all approach to psychotherapy. Over the past century, various psychotherapeutic approaches, including cognitive behavioral, person-centered, psychodynamic, and systemic therapies, have emerged from different theoretical and clinical backgrounds. Despite their differences, all psychotherapies focus on confidential conversations that are sometimes supplemented by exercises or specific interventions.

Unlike coaches or general counselors, psychotherapists are licensed healthcare professionals who provide regulated interventions. They are typically clinical psychologists or medical doctors who have completed postgraduate training or, in some systems, a dedicated psychotherapy degree program.

In countries where it is legal to practice therapy without a license, you should exercise caution when choosing a provider. Therefore, you should look for verifiable qualifications. General practitioners or public mental health services can help you identify appropriate and trustworthy options.

Adverse and Unwanted Effects

Emotional fluctuations are common during psychotherapy. Sessions may leave you feeling unsettled, sad, tense, or preoccupied, especially when addressing distressing experiences or conflicts. These reactions are normal and do not necessarily mean that therapy is ineffective or harmful.

At the same time, psychotherapy can have adverse or unwanted effects. Some patients experience short-term increases in anxiety, sadness, irritability, or self-doubt. Others report emotional exhaustion after sessions or relationship strain as established patterns begin to change. While these reactions may accompany therapeutic change, they should not be assumed to be necessary, beneficial, or self-correcting.

If distress becomes overwhelming, persists over time, or begins to significantly interfere with daily functioning, it requires an explicit discussion in therapy. The same applies to practical strain related to time, finances, or scheduling.

When Something Feels Off

While emotional distress can be part of therapy, it may also signal problems in the therapeutic relationship, and should always be discussed, as it might indicate malpractice or boundary violations. Be cautious if you feel pressured or intimidated, or if the professional boundaries become blurred.

You have the right to voice your concerns about therapy. Asserting your needs can be a corrective experience in itself. What matters is how your therapist responds. A competent therapist will address your concerns, listen carefully, and work with you to understand the source of your discomfort.

If a therapist reacts angrily or defensively, dismisses your concerns, or tries to make you feel guilty or blame yourself, this is inappropriate. In such situations, it is reasonable and justified to seek advice from another therapist, a patient organization, or a professional association.

Professional and Physical Boundaries

Psychotherapy is a professional relationship with a specific purpose and clear boundaries; it is not a not friendship. These boundaries exist to protect patients.

Professional boundaries include agreed-upon session times and locations, limited contact outside of sessions for practical matters only, and strict avoidance of personal favors, gifts, or exchanges. Social invitations, private meetings outside of therapy, and barter arrangements are inappropriate.

Requests for help with a therapist’s private projects or offers to exchange services for sessions violate professional standards. The therapeutic relationship should remain focused, professional, and time-limited.

Physical touch is usually not a part of psychotherapy. If physical contact is considered at all, such as placing a hand on someone’s underarm to express compassion, it should be an exception. Any physical contact requires explicit consent. You may refuse without providing an explanation.

Romantic or sexual relationships between therapists and patients are prohibited. In many countries, this prohibition extends beyond the end of therapy.

Your Rights as a Patient

You have the right² to be informed about the therapeutic approach, confidentiality, and fees; to ask questions and receive understandable answers; to be treated with respect; to be free from pressure or coercion; to access your own records; and to end therapy or change therapists at any time.

The Therapist’s Responsibilities

Psychotherapists have clear professional and ethical responsibilities. They must maintain confidentiality, engage in ongoing professional education and supervision, securely document their work, and use scientifically recognized methods. The use of esoteric belief systems and untested alternative practices are prohibited.

They must respect their patients’ dignity, autonomy, and right to make informed decisions about their care. Psychotherapists must not exploit patients emotionally, sexually, or financially. Furthermore, psychotherapy should not be used to recruit, persuade, or influence patients with regard to religion, spirituality, political ideology, or social movements.

Limits of Psychotherapy

Sometimes psychotherapy alone is not enough. Some conditions require different or additional forms of treatment. This may be the case when there is an underlying somatic cause that cannot be addressed through psychotherapy, such as with autoimmune disorders, or diabetes.

Severe depression, mania, acute psychosis, and certain neurological conditions typically require psychiatric and/or medical care. While a general practitioner can assist with referrals and coordination, they cannot replace specialized treatment when it is indicated³. In other cases, pharmacological treatment may be recommended to alleviate symptoms or support therapeutic change.

Seeking a second opinion or changing therapists are legitimate options if therapy is not leading to improvement or if symptoms are worsening. However, participating in multiple psychotherapies simultaneously is usually unhelpful and can cause conflict. For this reason, it is generally not recommended. There may be exceptions, such as during a time-limited inpatient or day-clinic stay, when treatments are coordinated.

Summary

Psychotherapy can be helpful but also demanding. Its effectiveness and safety depend on clear agreements, open communication, and firm professional boundaries. If something feels wrong, it deserves attention. A competent therapist will take your concerns seriously and treat you with respect. However, there is no need to approach psychotherapy with fear: in most cases, it is conducted professionally, and many patients experience it as a source of relief and lasting change.

Postscript

I wish you good luck in finding the right therapist for you. If you find this article helpful, please share it with friends or clients who might need it.

References

Based on the patient information brochure (“Beipackzettel”) developed at the University for Continuing Education Krems, 2014, and the research project “Risks, Side Effects, and Harm in Psychotherapy,” Leitner et al., 2012.

1. It is based on a patient information brochure developed at an Austrian university and on research about the risks and adverse effects of psychotherapy.

2. Please note that patients’ rights and therapists’ duties can differ from country to country, depending on local laws and professional regulations. If you are unsure, you can ask your therapist to explain which rules apply in your country.

3. After all, you wouldn’t go to a GP to have your teeth treated either.