If you have an injury or feel very ill most people don't bother thinking which specific hospital to visit or what doctor to see. The broad assumption is that an M.D. is an M.D., they are all well trained to deal with most sickness, so you just go to whatever seems more convenient. A small minority of people may go deeper than this and pick specific doctors or hospitals based on word of mouth, but this seems like a less common experience.

For people looking for a romantic partner, it is extremely uncommon that the first person they ever feel attraction towards ends up being their long term person. We understand that there is deeper match between the two people that is required, a certain je ne sais quoi to be present, and so one does not date "off the rack" as one does when picking doctors, rather one tries to understand oneself (what do I want, what do I offer) and the situation of dating. There's such a thing as "being good at dating and finding a partner". There is endless advice about how to go about doing this. In contrast there is comparatively little advice about "how to be a good patient" or "how to find a good doctor" because responsibility for the treatment is largely on the doctor and all doctors are relatively interchangeable compared to romantic partners.

I claim here that therapy is like dating, yet there isn't much writing on how to find a good therapist well matched to you, or how to know when it's working or not. This post is a small contribution to that small selection of writing. Some posts about choosing therapists I've liked though I don't endorse everything they say there:

What I'm saying here is colored by my own research and experiences; I haven't thought much of what would help someone with deep psychosis or "too much feeling". If you are a reader of Nintil.com you'll probably be on the highly intellectual side of the spectrum so thanks to the power of selection bias this post will most likely be useful to you, if you are therapy curious. For the "too much feeling" crowd I suppose that therapies that build more mentalization and conceptual ability may be more useful than trying to elicit more feeling, but I'm unsure.

I am interested in transformational and rapid change, not in therapies that take 10 years to work. This is the kind of therapy I have seeked (as an intense and somehat impatient person) and it has worked for me as I thought it would. As far as I can tell from published research around memory reconsolidation, this rapid change achieved through feeling feelings that were once painful to feel, hence my emphasis in this post on emotions and anxiety and less so on thoughts.

Why and when to go to therapy

There are many reasons to go to therapy, but some usual ones may be:

  1. You have specific concrete problems like insomnia, social anxiety, executive function problems, overeating etc. You think you'd be "better off" if you were different and you seek help to be different.
  2. You have a vague general sense that life could be more joyous, that people around you are having fun and "getting it" at a deeper level and you are not
  3. You want to understand why you are the way you are, perhaps coupled with (1 or 2)

The practitioners doing the thing called "therapy" go by many names: psychologists, therapists, social workers, and many types of coaches, but they all do something very similar at its core, if done well, through different mechanisms.

It's unclear to me when one ought to end therapy. As therapy progresses, ideally you'll feel better and your problems will go away, but you may also become aware of more and subtler problems you have, and at some point you may decide that you are done and stop it and go live your life. It may feel that deep enough in therapy the psyche feels like a whack-a-mole of fixing a million paper cuts and you may wonder if there's a root cause fix for all of this. There is, and the answer is Buddhism or similar practices. Sufficiently advanced therapy is spirituality, and pursuing meditation can also help clear out psychological issues in the same way psychotherapy can, a phenomenon called purification of the mind in Buddhist circles. You can see it in action at meditation retreats when you see people sobbing and shaking. The relationship between psychotherapy and spirituality is something the linked book talks about, and about which I might write in the future. For now, I'll briefly say that doing both and trying to see both as part of one overarching process of reaching towards well-being is a useful view.

Therapy modalities and therapists

There is an entire alphabet soup of therapy modalities like CBT, DBT, AEDP, EMDR, IFS, ISTDP and non-soupy one like Somatic Experiencing, Hakomi, Gestalt, or Psychodynamic Psychotherapy. Some of these are hailed as Evidence-Based(tm). I have spent a bunch of time reading about these and the debates around what "Evidence-Based" is supposed to mean in the context of therapy and left with the impression that one shouldn't put much weight behind such claims compared to first principles thinking and your own experience.

One particular problem I noted with "Evidence-Based" therapy is that there could be extremely powerful therapies that are fairly recent that haven't yet been studied. The Ideal Parent Figure Protocol (IPFP) for example, in a small study, has the largest effect sizes I've ever come across for dealing with attachment issues. There isn't much evidence for the IPFP yet so we can't call it "Evidence-Based". But here we are patients not scientists, we are not interested in highly repeatable intersubjective knowledge. Our question is "does it work for us" or "is it worth giving it a shot". The cost of the minimum viable version of the IPFP is just a textbook ($50) and ~30 min a day to do a guided meditation. I thought: if this does work, I could plow through my own disorganized attachment patterns at warp speed. If it turns out to be fake, I'll have learned a new thing that doesn't work and wasted $50. As it turns out the IPFP got me crying daily for around 21 days as I went through the stages the protocol says one goes through, and by my own subjective experience, I felt substantially more secure by the end. Whereas imagining an ideal figure caring greatly about my inner experience felt like intense heartbreak, now it feels like a nice warm experience. This doesn't mean the IPFP will work for you as self-therapy: by the time I found the IPFP I had been doing meditation for a while, and I have the attention span and patience to read a whole textbook about attachment theory and install an inner IPFP therapist in my head. Not everyone can do that as easily. But if you can, great!

This is all to say that you should consider your own situation and experiment until you find what works for you. Otherwise you may be like the many guys on reddit that got catfished by CBT, did it for many years and didn't get better. Often their story continues with "and then I tried a somatic modality and it worked great". Though note that somatic modalities too can fail patients, just because it's called parts work/IFS or "somatic" doesn't mean it will work for a given person at a particular time. Trust your experience!

How is it that sometimes an evidence-based modality fails a person and an unproven one does not? Is that person lying? Was their therapist deficient but the modality is fine? How come some people rave about somatic modalities yet they make others feel disillusioned? Because these things are all techniques that work for different people at different stages.

One of the most agreed-on things in predicting whether therapy will work is a concept called the "therapeutic alliance": how well you vibe with your therapist. This is what makes therapy hard to test scientifically and what makes it like dating. If you randomly assign someone to a therapist it's less likely to get a match well calibrated to where someone is at. If that person is allowed to go on a few "first dates" then it's more likely that a good match and a successful therapy will ensue. That then brings us to the question of "what to look for to know if something is working", in the next section.

Therapy modalities to some extent, I speculate, probably correlate somewhat with the personalities of the therapists that choose to practice them. A therapy modality like Hakomi will attract softer less confrontational personalities than a modality like ISTDP which is as spicy and violent (towards the defenses that get you imprisoned) as it gets.

Different people have different personalities and intensity of feeling that they can tolerate so what a person will find life-changing, another will find traumatizing, and conversely what someone might find suits them may be regarded as very slow by a different person.

How to know if it's working

Therapy modalities are all based on different assumptions about the psyche and do different things, how come they all can work?

After examining therapy modalities and reading a few books about them for a while, my conclusion is that they do get at shared mechanisms through more or less efficient methods. The skill of a therapist is deploying the methods that work in that moment for that person.

Memory reconsolidation is a phenomenon often pointed out as the driving core of most good therapy. The book Unlocking the Emotional Brain talks about this; essentially the idea here is that one reactivate a memory/schema/part from the past, then one rewrites it with counter evidence. Different therapy modalities disagree about how much can be done on one's own vs with the help of a therapist (AEDP posits an innate tendency towards healing and IPFP can be explicitly self-administered). I side with these modalities in that rapid therapeutic progress can be made on one's own and that the mind does tend towards healing indeed. Though initially that engine might need some kickstarting, so having more sessions initially until that's recognized might make sense. If you can't afford therapy, know that you can do a lot on your own, you are not a lost cause. And even if you can afford some therapy, if you want faster change, know that you can supplement your therapy sessions with your own daily emotional processing practice.

Usually, the reason we feel stuck is that we have an unfelt feeling; this unfelt feeling is painful to feel and is kept hidden from awareness. Therapists try to help the client unlock this feeling and let it run to completion.

A therapy session is working when there's some level of anxiety or emotion present. If it feels like a plain detached conversation, not much is happening. If you find yourself having mere chats with your therapist, find a new therapist. In an ideal world, your therapist has you sobbing in session one, but not everyone will want or be able to to take this level of intensity. It shouldn't take 10 sessions to know if it's working. If you are not feeling anxiety (a sign of repressed emotion) or emotion outright after a few sessions, switch therapist.

Another cue to watch for is a feeling of being "cornered" or "outsmarted" (that feeling is most likely coming from the ego defenses), the idea that a greater intellect (in an emotional sense) is seeing through you and making you somewhat uncomfortable, forcing you to see you don't want to see, where habitual ways of deflecting and looking away from painful stuff are repeatedly disabled by the therapist. There's such a thing as "too much" here and a good therapist will apply the necessary pressure and no more. It's okay if you don't feel understood by your therapist (and find that unacceptable), great news! Bring that up to the therapist, if there's anger there that can be followed to its root and processed.

Yet another thing to look for is surprise, in particular saying something that you hadn't said before, or shared with anyone else. Perhaps even saying something and then going 'wait, did I actually say that? Do I actually believe this??'. That's a good sign. For acts of speech, everything happens for a reason.

Some people say that "their therapist needs to be as smart or smarter than them" to truly help them. This is a limiting belief preventing you from getting better. The kind of understanding IQ brings you is not the understanding that brings progress in therapy. High IQ people most likely understand themselves as well as IQ can take them already. For high IQ people that have gotten ahead in life by being smart there can be shame in admitting that intelligence has limitations and that other skills are required to unblock oneself. I don't get the sense that the therapists that have helped me are smarter than me in the IQ sense but I still often felt like they were various chess moves ahead of me, seeing things I wasn't able to, and enabling me to unblock myself in ways I had been unable to on my own by thinking very hard. That said, if you are smart you'll make faster progress in therapy, all else equal.

Another limiting belief is thinking one is "not ready yet" for therapy because one can't feel one's feelings in the body or stuff like that. Indeed feeling feelings is part of the developmental arc towards greater wellbeing, but a good therapist should be able to help with that. The belief that one "has alexithymia" or "doesn't feel in the body because I'm that way" is great cope indeed (save major brain damage, perhaps). The thought "I can't feel" is most often a defense for "I won't let myself feel" because "It's too much to feel" or "it's painful to feel", but the feelings are there, from personal experience. It takes work and it can be anxiety inducing at first, but progress can be made! One tip that may help here is that if one doesn't have access to one's emotions one may need more intense approaches that not every therapist has familiarity with, sometimes involving movement (the Reichian lineages like Bioenergetics or Hakomi) or direct anxiety-inducing confrontation (a la ISTDP). So if you feel stuck because of insufficient feeling, try modalities like these.

Lastly, a therapy session should leave you feeling better, a skilled therapist should land you back to a safe spot before letting you go, even if the therapy had an intense cathartic component. If you feel dysregulated after a therapy session, communicate that to your therapist so they can adjust. If this persists, switch therapists.

Parts, schemas, shadows, defenses

The mind is not made of concepts, but in order to talk to each other we need to use them. This leads to the emergence of different vocabularies to make sense of a person's experience:

  • Freud had the id (the impulses), the superego (social demands), and the ego (the mediator between both)
  • Jung had a rich model with an unconscious, collective unconscious, the shadow, a persona, ego, and archetypes
  • IFS has parts (exiles, firefighters, managers) and the Self
  • ISTDP has the self and defenses
  • Gestalt has the topdog and the underdog
  • Core Energetics has the mask, the lower self, and the higher self
  • DBT has wise mind, emotion mind, and reasonable mind

It is important to remember that these are as real as you want to make them. If you go seek parts you will find parts, if you go seek archetypes you will find archetypes and so forth.

Use whatever works. Down the road, one starts to get closer and closer to a more accurate view (non duality of the mind) where one can look at the mind as parts that are also just one thing, and one thing that can be seen as parts. Some therapies probably encourage too much reification (assigning independent reality to these concepts) more than others. IFS can lead to this because it can be fun to talk about one's parts etc, but if one's doing the job well eventually the parts start disappearing, leaving just the self. In contrast, a modality like ISTDP posits a single thing (the mind/self) from the get-go, and everything else is something (a defense) to be pushed away. I like this more personally as it makes the job simpler and discourages a fracturing of the will, making the expression of anger and rage easier as well because it's always directed outward as self-defense. In IFS it's all "you" and being enraged at yourself is self-harming. IFS works, use it if you vibe with an IFS therapist you have found, just know that the parts are "real" not real.

A related topic to this is the causal model a therapy modality may use:

  • Past-oriented: Discussing childhood traumas and how those lead to dysfunctions in the present, how those may be stored in the body, and using those to access emotions. This is most psychotherapy since Freud.
  • Future-oriented: Looking at goals in the future as causing behaviors in the present. This is the Adlerian view, which is also present in the books The Courage to be Disliked, and the book Existential Kink. The idea here is that you have depression because you don't want to feel seen by people. Or you don't ask girls out because secretly you enjoy being single.
  • Present-oriented: Looking at what's right here right now. Prototypically this is Gestalt therapy, which need not go into traumas or goals, but affirms that all your problems are present in every instant of your perception, a perspective similar to Buddhism. ISTDP seems to also be like this.

These all can get to the same place: They all capture a useful view of the truth and they are not right or wrong, they are useful lenses at different times. The implication is that indeed you don't need to understand why you are the way you are (though you may want to) nor what goals you have. Those things can be useful sometimes. All you need to get started is noticing frictions in your life: things that trigger you or don't accept: therein lies growth.

Summary

To sum up, these are short term markers of therapy efficacy you can use to decide when to switch or continue therapy with a given practitioner:

  1. Emotions or anxiety being felt during the session. This is very important.
  2. Feeling (or thinking) that one is being outsmarted or cornered. This is technically fear but initially it can present as thoughts of "being uncomfortable" depending how much access you have to feelings.
  3. You feel surprised by the things you say. You have "aha!" moments.
  4. You feel better in some way following the session
  5. Over the medium term, you notice changes (new behaviors, being less reactive, feeling happier on average, etc)
  6. If your problem is difficulty accessing feelings, try an intense modality/practitioner