Help-Seeking and Status

Image credit: Rhoda Baer, National Cancer Institute

Image credit: Rhoda Baer, National Cancer Institute

[Related to How to Be a Good Depressive Citizen, this tumblr post and also this one]

I want to talk about something that plays out in the communities I love.

But first, I want to talk about schizophrenia.*

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There’s this feature of the onset schizophrenia that makes it extraordinarily hard to treat. We call the before-full-blown-schizophrenia stage ‘prodromal‘, and if you can catch it right in that stage, or close to it, your outcomes are much better.

Except.

Except that the big obvious signs of schizophrenia in that stage are negative symptoms: speaking in monosyllables, emotional flatness, anhedonia, disinterest in activities and relationships and friendships. And in most cases, this part plays out in relative silence.

Your friend stops reaching out to spend time with you, flakes out on group plans, seems bored in conversation. After a while, you stop being the one to call. They’ve found other friends, they just aren’t that into you, you’ve got other friends who put more work into the relationship. It’s quiet and it’s insidious, and I’d bet you don’t quite notice it until you run into each other at the store and wow, it’s been months since you hung out! 

For the most part, this is normal and natural–friendships do the slow fade* and fizzle and evolve. The vast majority of these things are not the result of an incoming bout of psychosis. So you can’t do much to address this. You could possibly make it the social norm to follow up on waning friendships until someone explicitly tells you they hate your company, but I imagine this as being hard to enforce and resulting in more excuses for ignoring other people’s boundaries. (If your solution is to only do this for friends you know are at risk for developing schizophrenia, then you may have even more forthright friends than I.)

So, what happens in most of the prodromal cases is that the person quietly retreats–maybe not even quite noticing that they are–and then when the positive symptoms of schizophrenia set in (hallucinations or delusions or magical thinking, etc), there isn’t a support system there for them. There aren’t friends there daily who can confirm that they’re going to work or taking medication. There isn’t friendship for friendship’s sake; relational interactions are important. And the extent to which this occurs is fairly predictive of outcome of the disorder. High social support means fewer episodes and hospitalizations, better medication adherence. Lower social support…doesn’t.

—-

And back to communities I love.

Communities have hierarchies. There’s variance in how much they’re enforced; there are levels of enforcement and policing and explicit/implicit acknowledgement of the rankings.

Except.

Except that this gets incredibly complicated in communities that are specifically about help-seeking, about coming together and supporting each other; the communities that are explicitly about Not Being Like The Rest of Society. Take, for instance, the mental health community. (Though you could almost as easily use the geek community, or other nerd/geek subtypes.)

The thing is, communities, even those created to be Not Like The Rest of Society, have values on multiple axes. Charisma, though perhaps a slightly altered definition, plays a role. Ditto for the halo effect, though attractiveness might be assessed slightly differently. And so through accidental privileges and intentional power-grabs, some people in the community end up more liked and more likeable.

I am not positive, but I would guess that it is somewhat harder to be in a community where you’re not supposed to be stigmatized, where your particular Problem isn’t unusual, and to have  all of that and watch them say “oh no, that sounds bad” and help everyone else more. And that this problem is magnified when the community you’re in is one you joined because The Rest of Society already did a bad job of caring.

And of course, people wish to prioritize helping their friends, and I think we mostly accept and encourage this. But it remains that some strangers will say “X happened”, and there will be an outpouring of support and love and empathy and praise. And you can have the same thing…maybe you have it worse, maybe you can’t afford to be so public about it, or don’t have the social support to let you present a showered and articulate and slightly-self-deprecating face. Maybe you don’t have the right language; you hate being crazy, you don’t know how to preface your anorexia-thoughts with how you know that healthy can be at any size, but sometimes your brain lies…because you aren’t at the place where you know it does.

And this is a problem. These are the people you want, in the abstract, to help the most–the ones who are new to the community, who aren’t already popular, who aren’t able to be effortlessly cared-about. They’re also the ones that can sound like they pattern-match for the people you’re in this community to avoid. They can be the ones who trigger you or make you slightly uncomfortable. And you joined this community to be safe and relaxed away from The Rest of Society, right?

—-

You can try to fix this, in these communities. You can assign people to make up the difference; to do the checking in and supporting. You can try to deliberately close the gap. Except that these communities also tend to put lots of value on being open and honest…and this sort of thing can quickly feel fake and dishonest. Not to mention, it’s work! You’re not being asked to comfortably inhabit your one safe space, you’re being asked to do emotional work to keep it. And The Rest of Society doesn’t do this, and weren’t you trying to carve out your own place that wasn’t emotionally exhausting?

But, in the mental health community, you’re in a community that’s explicitly about supporting people without ready access to society at large. So it might be even more important that you work hard to help more than just those who can passionately and lucidly explain their pain.

But…it’s easy to fall into patterns of identifying with charismatic leaders and using specific ingroup vocabulary, and helping the people who can tell you exactly and clearly what they need (with the implied understanding that if you’re busy or unable to help, they’ll get support some other way). Because there’s a difference between someone looking up at you and saying I need everything and I’m mostly okay, but could you do this one thing?  and diffusion of responsibility is a hell of a drug.

I…don’t have a solution to this. I’m not sure I even have part of one. But I do know that in my community, in the wide, tumblr and blog and activisty mental health community, there are those who get help, and those who get helped more.

Two notes: One, I’m not talking about privilege here in the classic social justice sense, because I see this replicate across homogenous groups who align on the commonly cited axes of privileges. For instance, I’d expect the phenomenon in a small group of equal-income, same-aged, same race friends. Two, by note One, I’m not saying we should ignore the role privilege plays, just that I had a word limit. 

*This…happens in real life more than I care to admit. 

**For the record, The African Violet of Friendship is sometimes a much better idea than the slow fade.

The [….]’s Guide to Getting a Therapist Masterpost

I ran a series last week about the finnicky steps of getting a therapist. This is the masterpost, with links to every part of the series. It will end up as a new tab on the top of every G&H page as well.

The [….]’s Guide to Getting a Therapist: Getting Started

The [….]’s Guide to Getting a Therapist: Reaching Out

The [….]’s Guide to Getting a Therapist: Your First Session

The [….]’s Guide to Getting a Therapist: Miscellaneous

Go forth and sit on couches!

The [……]’s Guide to Getting a Therapist: Miscellaneous

Fun fact: searching around for creative commons licensed couches results in lots of couches on fire. Is this a Thing?

Note: For decreasing the amount of language confusion in this post, I’m using ‘therapist’ as a blanket term to mean ‘someone who practices therapy’. In fact, this is not precisely accurate, though it seems to be colloquial use. For sorting between psychiatrist, psychologist, and therapist, take a look at the Terms section in Part I.

<< Previous Post: Your First Session

Part IV: In which forgotten things are unforgotten.

I am not a therapist! However, lots of people ask me a lot of the time about getting therapy, and are often willing to keep me updated on what worked and what didn’t. This four-part guide, which is essentially the sum total of every bit of advice I could think of, and a few I didn’t come up with (thank you, proofreaders and feedback-givers!) aims to make the therapist-getting part less mysterious and more accessible. 

—-

If you have had previous experiences where you found it hard to tell someone in person what had been going on, you might consider bringing in writing or notes. I have done this! It was very helpful, and meant I didn’t accidentally get too tangled up in my emotions and forget something important. Write poetry or journal in the moment and feel okay sharing it? Also a thing. Even my clinical training scenarios have included stories of clients bringing in such things, and if it means giving your therapist a clear picture of the issue it seems worth it. With one therapist, I showed up to our first meeting with data: a calendar reflecting how often I’d had trouble with my ED and significant events around each episode.

I’ve found it very helpful to avoid scheduling therapy between daily tasks. Sometimes there are surprise!emotions and I’ve felt much better when I had an hour or so to process the experience before interacting with people.

Despite liking my therapist(s) and seeing improvements as a result of therapy, I’ve often been tempted to skip sessions when I was having especially bad brain days. (If this sounds like a terrible plan, you’re correct!) My solution to getting around this was twofold. First, I set up a reminder in my phone to go off an hour before I had therapy. It read something like “Past-Kate wants you to remember that therapy makes you feel better and is worth doing” Secondly, I asked my partner to, if he ever thought of it, remind me of times when I felt really great after therapy, or point out progress I’d made. So far: success!

Sometimes insurance only covers a certain number of sessions (or your budget will only get you X amount of meetings.) I strongly encourage telling a therapist about this up front or as soon as you know—it can give them important information about structure and prioritizing how you meet, as well as allowing them to prepare you for termination of treatment.

What else would you add?

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<< Previous post: Your First Session

I am actively looking for things I’ve left out, so if upon reading any section, you have unanswered questions–even if you think they are trivial or might mean you’ve missed something, please let me know. I would much rather spend time responding with “no, that’s in paragraph two” than have a whole subset of people think they didn’t read properly and not tell me I was unclear. Further, many thanks to Rita Messer for checking over the advice within. 

The [……]’s Guide to Getting a Therapist: Your First Session

Fun fact: searching around for creative commons licensed couches results in lots of couches on fire. Is this a Thing?

Note: For decreasing the amount of language confusion in this post, I’m using ‘therapist’ as a blanket term to mean ‘someone who practices therapy’. In fact, this is not precisely accurate, though it seems to be colloquial use. For sorting between psychiatrist, psychologist, and therapist, take a look at the Terms section in Part I.

<< Previous Post: Reaching Out

Part III: In which couches are sat upon, forms are filled out, and intake is had.

I am not a therapist! However, lots of people ask me a lot of the time about getting therapy, and are often willing to keep me updated on what worked and what didn’t. This four-part guide, which is essentially the sum total of every bit of advice I could think of, and a few I didn’t come up with (thank you, proofreaders and feedback-givers!) aims to make the therapist-getting part less mysterious and more accessible. 

—-

Your first session:

The first session is an extension of the “Do you want to tango?” testing-each-other thing. The therapist wants to know if they can help your particular case, and you want to know if you feel comfortable/matched with them. It’s a first ‘date’ and if they’re metaphorically rude to the waiter, or you just don’t click, it’s okay not to start a relationship.

You might have to fill out some forms. This can vary a lot from place to place, but generally forms can include:

-acknowledgement of the confidentiality policy: therapists will keep nearly everything confidential, but they are bound by law and ethics in some very specific circumstances. If you want an idea ahead of time, here’s the gist.
-if you have medical or other psychiatric information that they might want or need, there’s a potential for signing releases to allow them to have this information. I’ve signed releases so that my medical info was accessible to my therapist and releases to allow therapists to have my previous therapists’ files on me. I was glad I did both these things, but you aren’t required to do so.
-In larger establishments like a health services center or such, it’s common for there to be initial diagnostic questionnaires, like a depression measure.

This session will likely involve very little Classic Therapy ™. Your therapist will be trying to get a feel for your issues and circumstances and might asks things like “Can you tell me what brought you here?” and ask about your previous mental health history.  I’ve also been asked if I was suicidal or had a history of suicidality and whether or not I had a history of being sexually assaulted or raped. The latter might be as a result of where I was seeking therapy—a women’s center, but I’m not certain.

The therapist should tell you about their approach and training. The American Psychological Association has a list of questions your therapist should be able to answer in your first session here—I highly encourage you to seek this information (and take it as a great sign when said therapist provides it without me asking.)

Therapies can also look quite different from practitioner to practitioner–one might be very structured and use lots of forms and worksheets (not necessarily a downside–I like these!), while another might be more informal or conversational. You can ask things like “What does [X therapy] look like in practice?” to get a better sense of this.

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Some thoughts on the experience of getting therapy for the first time:

Intake–the first session or the pre-first session–is exhausting. It’s telling all of what makes you need therapy and answering a fair number of invasive questions. I strongly recommend that people plan something relaxing and low stress (if you’re introverted, something that does not involve human interaction) for afterwards. Even thought I usually know what intake should feel like and have done it multiple times, I have to spend ~3 hours decompressing afterwards.

Most of the rest of therapy is not like this, but in order to have the relevant information, the therapist needs to have lots of starting knowledge about you. This is well worth it, but if at all possible, do not put your first therapy session between other scheduled and important actions.

—-

Some things to notice:

Does the medium therapist communicates with you in align well with how you prefer communication? I had phone-phobia for a while–therapists who didn’t use email weren’t worth it, because I’d never be able to get around the ugh field to call them and reschedule.

Does the therapist let you direct the session or do they initiate most angles or discussion? There’s not a One True Way. I prefer therapist-initiated angles of conversation (though I will sometimes point out that I’d like to focus on something time-sensitive), some people prefer the opposite. Noticing what you prefer here can improve future therapy.

 

Next post: Miscellania
<< Previous post: Reaching Out

I am actively looking for things I’ve left out, so if upon reading any section, you have unanswered questions–even if you think they are trivial or might mean you’ve missed something, please let me know. I would much rather spend time responding with “no, that’s in paragraph two” than have a whole subset of people think they didn’t read properly and not tell me I was unclear. Further, many thanks to Rita Messer for checking over the advice within. 

The [……]’s Guide to Getting a Therapist: Reaching Out

<< Previous Post: Getting Started

Fun fact: searching around for creative commons licensed couches results in lots of couches on fire. Is this a Thing?

Note: For decreasing the amount of language confusion in this post, I’m using ‘therapist’ as a blanket term to mean ‘someone who practices therapy’. In fact, this is not precisely accurate, though it seems to be colloquial use. For sorting between psychiatrist, psychologist, and therapist, take a look at the Terms section in Part I.

Part II: In which emails are sent, scripts are given, and therapists are contacted.

I am not a therapist! However, lots of people ask me a lot of the time about getting therapy, and are often willing to keep me updated on what worked and what didn’t. This four-part guide, which is essentially the sum total of every bit of advice I could think of, and a few I didn’t come up with (thank you, proofreaders and feedback-givers!) aims to make the therapist-getting part less mysterious and more accessible. 

—-

So you have a therapist (or several) in mind:

An introductory email or phone call is your next step. I find emails take less activation energy for me, as I can use the same default text over and over, and send them at any time. (update: see this comment)

You want to convey these things in your initial contact:

Who you are. (Not the deep philosophical version of this–your name will suffice!)
What you’re looking for (presumably, an appointment, but possibly a referral)
A general sense of your schedule (particularly important if you only have a few set times you are free)
A general sense of what problems you have, if you’re comfortable disclosing
Your insurance type and any other payment concerns.

Optional other information:

Previous experiences (have you seen a therapist before? Do you have prior diagnoses? Are you currently on psychiatric medication?)
Did you get a recommendation from someone?
Specific parts of your identity that might be worth disclosing (language preference, if the therapist speaks several, sexuality, etc)

Therapists sometimes aren’t taking clients or might not have experience in your relevant issue. For instance, if you write that you have trouble with OCD, and the therapist knows they haven’t got relevant skills, they might not want to take you on as a client.

Further, since therapists have a set of people they see with some regularity, they might not have a free space to add you. I’ve found it helpful to think of the initial interaction as asking someone to dance. You say “Hi, would you like to tango?” and sometimes they say “Tango? Fantastic!” and sometimes they say “Mmm, you seem lovely, but I only know the waltz.” or even “I love to tango, but I only know how to lead, and you only know how to lead and this sounds like it would be a problem.”

Scripts for contact:

(As a general note, therapists are Mr/ Ms/Mrs., psychologists and psychiatrists are Dr.)

Sample email (feel free to duplicate)

Hi [therapist],

I’m [name] and I’m interested in an appointment. Are you taking clients? [Because clients often are seeing a therapist weekly or every two weeks, timeslots can fill up, and therapists occasionally aren’t able to accept new cases]

I am experiencing trouble with [issue, with as much or as little detail as you’re comfy starting with/previous diagnosis]. Do you take [insurance type]? OR Do you negotiate sliding scale payment rates?

I have [work/school] on [days] but could do [general sense of free time, such as “weekends” or “Monday-Thursday afternoons”] If you’re not accepting clients, do you have suggestions for other therapists who might serve my needs?

Please let me know,

[name] [additional contact info if you prefer a phone call, etc]

Here’s an adapted version of an email I’ve actually sent:

Hi [therapist]

I’m [Legal Name], and I heard about you from [Campus Service]. I’ve had previous problems with an eating disorder (anorexia, currently well-managed EDNOS), and I’m looking to do some additional work on my coping mechanisms. I’ve had lots of success with CBT, and you list this as a modality you use. I was seeing [therapist at location], but with the new school year, am in need of a new therapist.

I have school on Monday-Thursday from 8-3, but am free after that and Fridays and weekends if you take weekend appointments.  My insurance is [Name of Insurance], and you list this as one of the ones you take.  Do you have availability? If you’re not accepting clients, do you have suggestions for someone else who might serve my needs?

Please let me know!

Kate

Next post: Your First Session
<< Previous post: Getting Started

I am actively looking for things I’ve left out, so if upon reading any section, you have unanswered questions–even if you think they are trivial or might mean you’ve missed something, please let me know. I would much rather spend time responding with “no, that’s in paragraph two” than have a whole subset of people think they didn’t read properly and not tell me I was unclear. Further, many thanks to Rita Messer for checking over the advice within. 

The [….]’s Guide to Getting a Therapist: Getting Started

Fun fact: searching around for creative commons licensed couches results in lots of couches on fire. Is this a Thing?

Note: For decreasing the amount of language confusion in this post, I’m using ‘therapist’ as a blanket term to mean ‘someone who practices therapy’. In fact, this is not precisely accurate, though it seems to be colloquial use. For sorting between psychiatrist, psychologist, and therapist, take a look at the Terms section.

Part One: In which potential therapists are found, modalities are defined, adjectives are adverb-ed, nouns are verbed, and info is dumped.

I am not a therapist! However, lots of people ask me a lot of the time about getting therapy, and are often willing to keep me updated on what worked and what didn’t. This four-part guide, which is essentially the sum total of every bit of advice I could think of, and a few I didn’t come up with (thank you, proofreaders and feedback-givers!) aims to make the therapist-getting part less mysterious and more accessible. 

—-

So you’re thinking about maybe seeing a therapist?

Psychology Today has one of the best therapist finders in existence. Enter your zip code, then use the categories on the left to narrow your search by focus, insurance, etc. However, therapists know that this is where many people find them, and capitalize on the search mechanism. This means two things:

  1. Therapists can list a bunch of stuff that they technically ‘have training’ in, without having spent time practicing said stuff. So, just because a therapist lists Cognitive Behavioral Therapy (CBT) doesn’t mean they regularly use it. Asking questions like “How much/what percent of your practice involves [my specific issue]?” can give you a better picture.
  2. Conversely, because therapists also can list a bunch of stuff because it will attract clients, you get opposite problem: don’t necessarily distrust a therapist because they say they’re trained in Rorschach–it’s not unusual for grad programs to teach it, because some people really do want a Rorschach administered.

Lots of therapists practice Cognitive Behavioral Therapy and other things. A therapist you find that lists CBT might not immediately practice CBT on you. You can circumvent this by explaining that you’d like to do CBT. (Telling them you’d also like to know if they think it’s not working or some other modality is better will probably make this request go more smoothly)

CBT is not the only evidence-based therapy, and I actually don’t always recommend it to people if they already introspect and self-CBT regularly. [Here’s a bit about why].

Another way to get a therapist is via referrals. You can ask your medical doctor, friends who have seen therapists, or friends or acquaintances who are therapists. I’ve had more success with the last, but the more recs the merrier! You can look them up on a site like the Psychology Today therapist finder to get specific information like what insurance they take. If some seem like they could be a good fit, you can set up an initial meeting or two. (It may be a good strategy to see several people before picking one who seems the best fit). The next section of this series will handle setting up an appointment.

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Terms

Licensed therapist: Varies by state, but someone who holds a license to practice therapy, but not a PhD. Includes Licensed Social Workers, Licensed Therapists, and Marriage and Family Therapists. Further info here.
Psychologist: Has a PhD or PsyD, has done a one year internship, generally more expensive. I don’t find their practice of therapist to be significantly better–it often seems worse. I’d suggest a psychologist over a therapist for children (because of the amount of developmental psychology training needed) but not otherwise.
Psychiatrist: Has a medical degree. Psychiatrists are quite expensive. As a result of this in combination with their nearly unique ability to prescribe psychiatric medication, (Psychologists may in a handful of states) they’re often seen specifically for this.

—-

Spend some time thinking about your preferences! Do you think you’d prefer to talk to someone of the same gender? Race/ethnicity? Are there particular parts of your experience that you particularly need a sensitive ear for? For instance, poly people who anticipate needing to discuss and dissect parts of being poly might want to ask a therapist about their knowledge of polyamory. However, if you’re poly but don’t expect it will come up much or be central, you might not need to select for this, and could save yourself some work by not prioritizing it.  Poly, queer, kinky people can find some help for friendly therapists here, as well as here.*

For young people, particularly young people who interact a lot with social media or tech, I sometimes advise finding someone close in age to you–even someone currently working towards a license in psychology–they’ll be used to experiencing life in some way close to yours. Secondly, people in this stage of working usually seem to treat therapy as a collaborative measure. Thirdly, I’ve found that it feels a little easier to question your therapist about the direction of therapy or raise concerns if they are closer in age to you. This by no means means that non-age-matched therapists won’t be helpful, but it’s served as a useful heuristic for some.

—

But what kind of therapy? There are more types than the ones I list below, but these crop up a lot. Wikipedia has been the best single resource I’ve found for short explanations of those not listed below.

CBT: pretty much what you expect. Working on cognitive and behavioral aspects of issues in question.

DBT: Dialectical Behavioral Therapy. Mindfulness based therapy. CBT meets awareness and acceptance training, as well as distress-tolerance. Here’s a great summary.

REBT: Rational-Emotive Behavioral therapy. Created by Albert Ellis. Philosophy meets CBT. The Wikipedia article is excellent. You can see demonstrations at the Albert Ellis Institute in NYC.

One of the best predictors of therapy succeeding is something called the therapeutic alliance–the sense of collaborating together, both working on a problem, sharing, caring, etc. In essence, do you ‘click’? If you don’t feel like you click with a therapist, this is a great reason to go find another. You can even tell them that you don’t think the therapeutic alliance is working out–this is the ‘code word’ for a specific way of things not working. Knowing this can also make it feel less stressful to explain why you don’t want to see said therapist; it’s a great script. (Therapists who respond badly to this are not good therapists on the whole.)
[I wrote some things on the therapeutic alliance here, but they’re not directly relevant to this bullet point.]

CBT often involves cases of questions or lines of questioning or roleplaying that can feel silly. I usually frame this as something that can feel weird, but is intended to get your emotional and intellectual reactions into place. You might know intellectually that no, all your friends don’t hate you, but still have panic attacks.  The point of the exercise is less about knowing in an intellectual sense and more about installing habits of thinking that will prevent the panic or anxiety your emotional brain is doing. Some people can get into this paradigm easily, some find it hard to suspend their annoyance at obvious questions.

Next post tomorrow: contacting potential therapists!

*If your therapist isn’t familiar with non-monogamy and you want backup, this guide is aimed at clinicians. 

I am actively looking for things I’ve left out, so if upon reading any section, you have unanswered questions–even if you think they are trivial or might mean you’ve missed something, please let me know. I would much rather spend time responding with “no, that’s in paragraph two” than have a whole subset of people think they didn’t read properly and not tell me I was unclear. Further, many thanks to Rita Messer for checking over the advice within. 

 

The Therapeutic Alliance and Just….Not ‘Getting It’

No, I didn't spend lots of my afternoon creating a logo for a fictional, crime-fighting Therapeutic Alliance. What makes you ask such a thing?

No, I didn’t spend lots of my afternoon creating a logo for a fictional, crime-fighting Therapeutic Alliance. What makes you ask such a thing?

[Related to Some Musings on Cognitive Behavioral Therapy and Counterintuitive Underreactions and Overreactions]

There’s a lot of talk in my clinical classes about who and what succeeds in therapies. Does it matter if you’re a matched or unmatched gender from your client? (Probably not, except maybe for teens. ) What about matched ethnicity? (Maybe for some ethnicities.) Does it matter what sorts of therapy you’re practicing? (Sort of? Maybe. Okay, we’ll concede that we disagree a lot.)

But there’s this one thing that we do think is important, across all sorts of other variables. The therapeutic alliance. Sadly, not a secret cabal of psychotherapists, fighting crime and kicking ass.

[Psssst, I would TOTALLY JOIN if someone reading this were recruiting for such an alliance. Ahem.]

Therapeutic alliance is the sense of working together as a team, client and therapist. Depending on who you talk to, it involves empathy, reciprocated positive feelings, a sense of collaboration, and the client’s belief that the therapist supports them. More interestingly, it’s a fantastic predictor of both whether or not clients will stay in therapy and whether or not therapy will result in positive outcomes, across the type of therapy.

…Okay, not exactly earth-shattering. If you don’t feel like you and your therapist are on a team, or don’t feel as though you’re supported or understood, you’re not going to want to go back to therapy and spill your heart and guts. You’ll want to find someone else or stop paying for hours of awkward and uncomfortable interaction. If you don’t feel like your therapist understands what’s going on, where are you going to dig up motivation to practice the (hard) skills you’re developing in sessions? If you don’t think your therapist empathizes with you, are you going to tell them when you failed? If you don’t tell them when things fell apart, how are you going to develop coping mechanisms for failure modes? Of course you’ll put in more work with a therapist you want to please, and that will show in better outcomes.

Right okay, so the importance of the therapeutic alliance makes intuitive sense too.

Except, imagine that your professional success hangs very much on being able to make people with a wide variety of backgrounds, cognitive distortions, and expectations for therapy like and trust you within the first few hours you spend together. And your job is to do this over and over and over.

And the advice you get for how to do this involves things that seem to be on the simplistic side. Don’t seem distracted. Don’t watch the clock. Don’t invalidate their emotions. Don’t seem judgemental. Great advice! But not exactly going to turn you into the perfect stranger to share deep and scary secrets with.

In trying to pull this apart, I’ve a theory, which generalizes outside of couch-based relationships. When people say lots of words at you, picking which ideas you respond to is important.

Again, not earth-shattering. Boring and mundane, even. Bear with me.

An example, from the non-therapist version:

Jeremy: Hey, I noticed you’ve seemed a little upset this week. Is anything going on?

Eliza: Yeah, it’s been a rough week. My parents have been fighting constantly–you know, the loud, shouty fights that you can’t not hear. I’m afraid they’re considering splitting up. And I’ve been stuck at home because my car’s in the shop; I have no idea how I’m going to afford the repair I need.

Jeremy: Yeah, I hear you. It’s almost impossible to take a car in and not have to spend a ton of money.

…and at this point, I bet a bunch of you are patting yourselves on the back for spotting what happened. Go you! Jeremy asked after Eliza, who helpfully explained she had BIG STRESS X [parents shouting constantly and unavoidably] and Small Stress Y [cars are expensive to repair]. Given the opportunity to respond to X or Y, Jeremy commiserated about how cars are expensive to maintain.

If Eliza and Jeremy are close, she can agree and then turn the conversation back to shouting parents, or decide that Jeremy’s response doesn’t condemn him as Worst Friend Ever, and find someone else to pour her heart out to later.

And I want to throw some sympathy in Jeremy’s direction! “My parents are shouting and might be splitting up” is not light conversation and I’d bet that his internal monologue sounded like “helphelphelp, what’s the script for this, OH, I know how to talk about repairs being expensive!” or “oh noooo, that sounds really hard, what do I say next? uh oh she stopped talking now I talk aaaaah”

Point is, this might be frustrating for Eliza if it’s the default mode of their friendship, but I expect it’s unlikely she’ll even notice at the conscious level it’s happened this one particular time. Most people simply don’t analyze friendships at the level where they can articulate “I expressed two worries and Jeremy picked the lesser of the two to discuss, when clearly the greater worry was my parents marital status”, nor do they need to.

Let’s go back to therapists and therapeutic alliance. I think that lots of what stymies the therapeutic alliance is a version of this. Except instead of having a background of friendship and understanding, there’s this client, who maybe isn’t even sure therapy can help, and what if this person makes fun of these weird feelings like everyone else did? There’s all these unseen, not-quite-expressed negotiations where the therapist is trying to get information without interrogating and the client is trying to test the waters with progressively more personal information and lead the therapist towards asking the questions that will let them do that.

So, Client Eric says that he’s been worried about school and can’t sleep because he’s had so much homework. And Therapist Evangeline wants to talk about coping techniques for dealing with school–which helps Eric. But Eric, who has only met Therapist Evangeline once before, at intake, was hoping she’d ask after that not-sleeping part, because he’s had insomnia for a few years and everyone else thinks it’s normal college behavior, but a few times he didn’t sleep for days and what if that’s really bad…?

Client Eric might be able to fix this if he points out that he wants to talk about his sleep, and does Therapist Evangeline mind, but that’s hard, especially if Eric’s mindset is that the therapist is the expert who will fix his brain. It’s not that this is a bad mindset, it’s just that Correct the Authority Figure” is a harder game than Correct the Nice Stranger Sitting Across From You.

So after a few sessions where Eric says A and B, and Evangeline focuses on A, when Eric’s worried about B, Eric might feel like he’s not being listened to. He’s not right, exactly–Evangeline is listening. If you press Eric, he might be able to tell you that she just….didn’t get it.

And I think this is basically what makes the therapeutic alliance fail between some clients and some therapists, all other things equal. For some set of clients, a therapist is great at figuring out what part of a given response to hone in on, and for some other set, they miss enough to give the feeling that they’re not paying attention or don’t care or just…don’t ‘get it’

I…don’t actually know how to fix this. Or if it’s fixable. I know that being able to label this difference between a therapist I adored and a therapist that was meh made me feel more in control. I wasn’t unreasonable, it was that I kept wanting to talk about Thing One, and they kept asking after Thing Two, which in my mind was more a detail to round out my story than a Large Problem. Once I was there, I could point out that my concern was Thing One, and did they mind if we explored that? It was tiring, and all things being equal, (they weren’t) I would have found another therapist. But instead of therapy being a nebulous and confusing interaction, I could pinpoint exactly where the exchange was getting unhelpful.

 *For the record, this is probably overly simplistic. If you’re trans*, I’d bet it would make things a lot more relaxed and open if your therapist were too, along with some other permutations that probably haven’t been investigated closely. Further, my guess is that the effect is fragile for most of these differences anyways.