Therapy can be confusing. It’s expensive. It’s time-consuming. It’s also weird and confusing.
The diversity of approaches is staggering – IFS, CBT, DBT, Somatic, Psychoanalytic, on and on. Anyone you talk to has tremendously strong opinions about what works and what doesn’t, what’s “correct” practice and what’s borderline abusive.
The narcissism of minor differences reigns, and orthodoxies and denouncements flourish. (Some of the arguments border on such absurdity that they stop just shy of mimicking a Monty Python sketch.)
This isn’t useful if this is your first time in therapy and you just want to get the most out of the process. I’d like to help with that.
Therapy is expensive. It’s time-consuming. It’s also weird and confusing.
The diversity of approaches is staggering – IFS, CBT, DBT, Somatic, Psychoanalytic, on and on. Anyone you talk to has tremendously strong opinions about what works and what doesn’t, what’s “correct” practice and what’s borderline abusive.
The narcissism of minor differences reigns, and orthodoxies and denouncements flourish. (Some of the arguments border on such absurdity that they stop just shy of mimicking a Monty Python sketch.)
This isn’t useful if this is your first time in therapy and you just want to get the most out of the process. I’d like to help with that.
Let Me Virgil You Through This Inferno
I’ve been in way more therapy than the average person. While I understand that this isn’t the coolest flex, it’s helped me understand therapy both as a patient and as a provider.
It’s a product of both needing it at various crossroads in my life, becoming obsessed with it as both a professional interest and a hobby, and a, let’s say, historically “relaxed” attitude towards financial planning.
For the data-minded folks out there, I’ve probably been in therapy for about 20 years of my life. This includes half a dozen individual therapists, a few group therapists, and countless workshops. I’ve had life-changing therapy experiences, neutral ones, and a few that have caused me real harm.
As a therapist, I’ve done my 10,000 hours (figuratively speaking, I know that idea is a bit squishy): I’ve been on the other side of the couch for a few hundred patients, got certified as a group therapist, sat on the board of a psychotherapy research group focusing on how and why therapy works across disciplines, taught on psychotherapy regularly, and supervised and consulted with other therapists.
It would be terrible hubris to say I’ve got “the” answer, but I’ve been around the block enough to offer up my five key insights for getting the most out of therapy.
Tip 1: Vibes First – Does It Click?
You wouldn’t know it from how people advertise therapy, but the techniques your therapist uses generally don’t make the biggest difference, not by a long shot. Time and again, research and meta-analyses continually show that the reigning paradigm of matching diagnosis to technique does not predict success in therapy nearly as much as the perceived match between patient and therapist.
What does “perceived match” mean? Honestly, that the vibe is basically good. You like talking to your therapist, you sense they understand you well, you trust that they’re competent, that they have your best interests at heart, that you feel more at ease around them as a person, and that they’re responsive to what you need.
I always recommend that people speak with a few therapists when they’re looking for the first time. You’ll immediately begin to see how different therapists are and how you click with different people.
It doesn’t mean the therapists you don’t click with are bad. You just may not be a good fit, and that’s okay. And it doesn’t mean that a therapist’s training and experience isn’t important. It just means that if you don’t vibe with them, it’s really hard to get anything else done. Intuitively, it makes sense. It’s hard to get help from someone you just don’t feel comfortable with.
So while there’s a ton of information about diagnosis, techniques, expertise, etc., it remains ultimately valuable to just get a simple sense of whether you click with your therapist or not. If you don’t, you should probably move on, unless the other tips below come into play.
Tip 2: Focus In – Get Specific
Here’s a common scene from a therapy session:
Patient: “They didn’t empty the dishwasher or ask me how it went. I feel sad and lonely all the time. They never have a good sense of my needs and they just don’t care about them at all. It’s always like this and I just get so down about it. They’ll never change.”
Therapist: “Very painful. I know this is a common feeling for you and a huge source of frustration. How do you talk to your partner about this?”
Patient: “Oh, I’ve told them lots of times.”
Therapist: “That’s good. Tell me how that conversation goes.”
Patient: “What do you mean?”
Therapist: “I mean, imagine I was a fly on the wall during one of these talks. What did you actually say?”
Patient: “I said, ‘Oh, you didn’t empty the dishwasher? Fine, I’ll do it.'”
Therapist: “And then what?”
Patient: “I just didn’t talk to them the rest of the night.”
Astute readers will pick up what we’re putting down here. The stories we tell about what happened are almost never what actually happened. We tend to create those stories during the events, then retelling them afterward leaves gobs of information to be lost in translation.
Focusing on what you actually say to people and how they actually respond can reveal both the landscape of our inner world (the stories we normally tell ourselves—spoiler for tip 3) and new paths to approach old problems.
Using the above snippet, we can now revisit any number of different ways to talk to one’s partner about the dishes, the loneliness, and the frustration. So to get the most out of therapy, sweat the small stuff.
What do you actually say, how do people respond, where’s the gap between what happened and your story about it? Of course, it’s worth mentioning that a good therapist will help you do this and help draw your attention back to the salient details to help you make changes.
Tip 3: Zoom Out – Think in Themes
Paradoxically, zooming in on the details often leads us to the bigger picture. What are the themes that wind up repeating themselves in your life?
Our minds don’t see the world clearly. In fact, they’re always seeing the world through the lens of our past experience, and we co-create the world we experience in any given moment. Honestly, this is where neuroscience collides with mysticism and/or insights from your stoned friend.
Here’s a simple little example showing how our preconceptions change our experience.
With sound waves, a curiosity.
Expanded to how we understand ourselves, our lives, the world? Profound.
Look for things that “always” happen to you. Are you “always” unlucky, alone, frustrated? Look for things that tell you “how the world is”: unfair, uncaring, or punishing. And look for how other people always are: sneaky, unfair, distant.
These things, I am almost willing to guarantee, help us understand ourselves and our past experiences more than they are accurate pictures of the world. The world is, of course, all those things, but it’s also much, much more at any given time.
The more you and your therapist can focus on these themes, the quicker the pathway forward tends to reveal itself.
One super tip that’ll be expanded on in tip 5: notice any themes from other areas of your life that are repeating themselves in your therapy. Usually feel like others aren’t interested in you, and now your therapist doesn’t seem to be either?
Other people are dismissive of your concerns and find you frivolous, and now you think your therapist feels the same way? Believe it or not, this is pure, unadulterated therapy gold. Tip 5 will go into it further.
Tip 4: Pet the Dog Backwards
Henry Ford said, “If you always do what you’ve always done, you’ll always get what you’ve always got.” Putting aside the irony that this was said by the fellow who invented the assembly line, it’s a truism useful to us and your psychotherapy.
Therapy is, mostly, a process that should change us. In order for change to happen, well, something has to change. While you may file this under “duh,” it’s harder than it sounds.
Most folks come to therapy after everything else they have tried has failed. While “the answer is almost always where you least want to look,” the truth is that the answer often lies in what you least want to do.
So people who come to therapy feeling like they’ve exhausted all their options often realize quickly they do have more options, they’re just the ones they ruled out or overlooked because they’re too scary, demanding, or counterintuitive.
Experience is the language of the brain. Experiences that prove to you it’s safe to go about things in a new way are the royal road to change.
Afraid of conflict? You need to have some conflicts. Anxious about contamination fears? You need to handle some things you’re afraid of. Terrified of intimacy? You get it.
This doesn’t have to be like psychological cliff diving. Therapy often helps us scaffold into trying things we’re frightened of by understanding where the blocks arose, practicing skills to make them easier, and providing support. And, along with all that, ultimately you will just have to jump off the diving board at some point.
To get the most out of your therapy, at some point you’ll need to do the things you’ve been avoiding.
Tip 5: Tell Your Therapist They Aren’t Cutting It
Generally try to be nice about it, but if your therapy isn’t working, you should bring it directly to your therapist and let them know. A couple of good things can come out of this.
First, well-trained therapists will be thrilled, generally, to hear that you want something out of therapy that you aren’t getting. I often tell patients that I can’t adjust how I’m working with them if I don’t know what they need.
As much as I try to intuit it, I rely on feedback to make therapy really work. Do you want me to talk more or less? Does empathizing feel good, or do you need more problem-solving? More David Goggins or more Brene Brown? Feedback helps us do better.
Second, this can surface bigger themes in your life (tip 3) that could be incredibly helpful to your therapy process. This is especially true if something feels like it’s being repeated in therapy.
Spoiler alert: it’s unlikely (though not impossible) your therapist is bored, judging you, or wants you to do x, y, or z, but the fact that you feel like it’s happening is the golden opportunity to take that pattern apart and try to do something different with it (tip 4). Some of my most powerful moments as a patient, and as a therapist, come when we get into these areas together.
Third, it may highlight a therapy that isn’t working. It’s okay, sometimes that happens. I’ve muscled through at least two therapies that, in retrospect, I knew really weren’t right. While in the long run, I’ve found ways to make those experiences meaningful, they didn’t have to be so hard, didn’t have to go on so long, and I didn’t have to spend so much money on them.
So how do you tell a productive rough patch with a good therapist from one that’s just a bad fit? It’s tough. Here are some guidelines:
- If this pattern feels familiar to other relationships, it’s probably worth sticking with it to see if something can change.
- If the therapy initially felt good and then hit a rough patch, it’s often worth sticking with it to see if something can come out of it.
- It’s usually worth trying for a few sessions if you aren’t sure. People step on each other’s toes in relationships sometimes.
- What would “petting the dog backwards” be? Do you tend to stay too long in bad situations? Maybe it’s time to experiment with leaving sooner rather than later. Do you bolt frequently at the first sign of trouble because everyone disappoints you? Maybe you should stay longer this time to see what’s on the other side of that.
For the record, it’s also worthwhile to tell your therapist when things are going well and you feel especially seen, close to them, safe, or connected. This isn’t to make your therapist feel good, though sure, it’s nice to know things are going well, but more importantly, it’s so both of you can zero in on what happened that helped you arrive at that spot so you can get more of it in your life and other relationships.
Ready to Get Started?
Even I, someone with 25+ years as a patient and 15+ years as a provider, find looking for a new therapist daunting. For folks outside the field, it’s an overwhelming mess.
But if you’ve been stuck in analysis paralysis, let me give you a gentle nudge to get the process started with a few intro calls. Like I said, you’ll get a strong sense of how different people feel just by making contact with a few therapists. I know it’s daunting, but it’s worth doing a few intro sessions to really find someone who clicks.
Give us a call and see if things feel like a match. We’ll either have someone for you or be happy to connect you with other providers who would work well with you.
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Trevor M. Ahrendt, PsyD is one of the co-founders of The San Francisco Therapy Group. He practices online and in-person in SF. He provides individual therapy, psychotherapy training, and case consultation. He also owns too many stereotypical therapy sweaters but remains a sucker for a chunky knit rollneck cardigan.
