Category Archives: Therapy

Therapy

Procedural Executive Function, Part 1


In this series I divide the 8 aspects of executive function into three parts that I consider roughly sequential in how people experience “deliberately doing something,” from start to finish, to point out pitfalls and how they can be dealt with.

Before starting, it’s important to take an extra moment to specifically emphasize that this is a process with multiple steps. Part of what I hope people learn from this is to better understand which aspect of the process is blocking them when they feel stuck with their own executive dysfunction.

So if I focus on a certain aspect of the process and share a perspective on how to help ensure that part goes smoothly, that doesn’t mean the assumption is everything will go fine as long as that one aspect does. For some actions you take, the whole process will go smoothly. When it doesn’t, the part that trips you up will likely change depending on personality, diagnoses, the type of action you’re taking, or just the context of your life at that moment.

We’re first examining these parts individually so that we can then examine how they interact more systematically; no part of this process should be taken as a final, normative word on how your own inner workings must look. But I hope it will be helpful nonetheless.

(As a final note, I won’t talk about medical solutions to Executive Function, as it’s outside of my area of expertise. I hope to add more resources for that at some point.)

Planning/Prioritizing

The first step of any intentional act can be called the “notion” to act. Notions themselves are involuntary, often vague, and not particularly compelling. They’re just an idea, summed up generically as a thought like “oh, that’s a thing.”

This sometimes comes with a should attached. “I should study” or “I should throw out the trash.” But the more neutral version is simply a could. “I could get a drink” or “I could watch some  TV.” It can also be nonverbal; just an image of something, maybe with a vague sense of desire or worry.

Once the notion occurs, a few things might happen automatically (that is to say preconsciously):

  1. Our mind discards the notion, sometimes so quickly that a few moments later we might not even remember having it.
  2. Our body starts acting on it, such as by walking to the fridge or alt-tabbing to a web browser.
  3. Our imagination starts to plan out how we might do it, or simulate what doing it might be like, or envision what the outcome might be.

We often become aware we’re doing the 2nd one as we do it (though it can take a surprising amount of time), and then decide if we want to continue or not. If the thing is enjoyable enough, it might be hard to stop. This will be covered more in future articles.

The 3rd one, if noticed and latched onto, can then be continued consciously. This is the first point at which intention enters play, which makes it the first relevant step of executive function; by definition, something is only a result of executive function if it’s intentional.

It may seem strange to count “what you decide to do” as part of executive function, but this is why it’s important that Planning and Prioritizing are grouped together; before you decide how to do something you must decide whether you actually want to at all. And your reasons, context, and frame for prioritizing something is all upstream of how “motivated” you will feel to overcome the various other challenges that might come up during the process, including the actual initiation of the task.

So how do we do that?

It’s difficult to make a full list of things to prioritize for; there are multiple entire frames you could use before you even start listing things, such as short term vs long term, or selfcare vs productivity, or explore vs exploit. Or you can divide your life up into different areas and goals, such as Health, Work, Leisure, and Love and then decide what to prioritize based on which is lowest, or which feels the most valuable in the moment.

Whatever the category or specific thing being prioritized for is, the first step to avoiding executive dysfunction is recognizing what feels, for lack of a better word, alive. That can mean “fun,” even if challenging, or “compelling,” even if scary… these are just a couple of the many words we use to refer to specific emotions that make up the umbrella term “motivation.”

Motivation comes up all the time when talking about executive (dys)function. Sometimes it’s called “willpower.” Other times people refer to its absence, “akrasia,” when they wonder why they’re struggling to do things they, ostensibly, want to do.

But this is why distinguishing actual “wants” from feelings of “shoulds” is important. There will always be more notions to do things than things you end up having time to do, and always more “shoulds” that you will feel pressured to follow than the ones you endorse doing.

Again, prioritizing is crucial to executive function. It’s how you avoid not just decision paralysis on one hand or regret on the other, but also how you avoid motivation traps (simply not caring enough about the thing to do it, despite feeling like you need to). Trying to do something that doesn’t feel alive is similar to getting a car from one place to another without enough gas; the less you have, the more you’ll have to push.

So what does it mean to prioritize based on what you “want,” in a world that’s so often full of things you “have” to do just to survive, or maintain basic quality of life?

There’s no easy answer to this, as your wants are to some degree a reflection of reality. There may be some activities that just are more fun than others for you in the territory. There may be some outcomes that just are more scary than others for you. There isn’t anything wrong with recognizing this.

But we understand reality through models, and our maps of the territory can change as we gain new knowledge. Some activities turn out to be more fun than we at first think they are, either with experience or with the right knowledge of how to do them a different way, and our motivation to do them increases. Other times we reframe our expectations or experience of an activity, and it becomes more or less motivating based on the attitude we take, or the predictions we have, about it. Genuinely believing that failure is just an opportunity to learn and grow makes activities with uncertain success less daunting to try, but of course this is more difficult the stronger the negative consequences are.

This may seem obvious to some, but it’s worth spelling out that this means our ability to simulate what will happen if we do something, or don’t do it, is actually fairly important for how motivated we feel to do it. If you can’t clearly visualize the steps from where you are to where you want to be, it’s much easier to end up feeling stuck, lost, or adrift.

(For those with aphantasia, the alternative process might be similar to what you do when thinking of something in the future you’re excited about; I’m not sure how analogous this is, and would love to hear from anyone who has trouble with mental visualizations, or see research on whether there’s a connection between the two)

We can also find more clues to why things might be emotionally difficult to do by looking at the reverse: habits.

Endorsed or not, we tend to feel no particular rush of motivation or painful akrasia when doing habits because, in order for an action to become a habit, we’ve done it so often it has become predictable. There’s no chance of failure, and no need for thought to ensure a particularly good outcome.

(Probably worth noting, it seems that some people really just don’t form habits, or at least the threshold for forming habits is much higher for them such that the closest thing they experience to being able to do things on autopilot while thinking about other things is something like “walking” or driving.” This is also something I’m curious to hear/learn more about.)

All of which leads me to my first crystallized insight from research:

Executive Dysfunction most often occurs when the next step between where you are now and what you want to do is difficult to imagine, and/or painful in some way.

Task Initiation

This, ultimately, is why a lot of the leading advice for clearing ugh fields are things like “break things down into smaller steps” and “check if there’s anyone you can reach out to for help” and “try approaching the problem from another angle.” It’s also why just talking through a fear and being reassured that the reality won’t be as bad as it seems can help people do things they’ve been putting off.

I suspect it’s also why just having company around can help people get through things they expect to be unpleasant. There’s a sense of ambient safety that comes from being around those we trust to support us, even if there’s nothing in particular they can do about the bad-stuff that we imagine. On top of that, as a separate thing, having pleasant company and conversation can just make unpleasant tasks easier to do.

This might seem really basic, but is worth highlighting as separate from social pressure or worries of how you’ll look to others, which tend to be how people perceive accountability partners or similar. Those can definitely have influence, but for many they’re aversive rather than compelling, and these more positive frames can be more valuable.

But those are all just a few ways to unblock the initial spark/decision/compulsion to do something you deliberately plan to do. If you don’t focus too much on deliberate steps of an action, you might find yourself able to do them more easily by just following notions; “non-doing,” or wuwei, is a phrase often used for this state. Of course, you also might find yourself non-doing something else other than the thing you “intend” to (that’s rather the point).

But that this “cheat” can work at all indicates again that there’s something about deliberate attention and focus that can evoke things which demotivate us, or paralyze us with indecision or fear. Acting before your conscious thoughts can get in the way is, in many ways like putting yourself in a state of total freedom from consequences; consequences only impact our behavior when we know about and believe in them, after all. This is a great strategy when the risks or consequences aren’t “real.”

Not that non-doing is fool-proof, even if you invoke it and and follow the “right” notion to, say, sit in front of your computer and open your email inbox; once you’re face to face with a difficult email, it might bring your attention back to the things that made it hard to answer them in the first place, sending your attention to something less uncertain or painful. But again, we’ll cover that in a later section.

How does task initiation happen at all, given the existence of multiple different possible acts you could take? What tips the mind in the direction of one over another?

At some level a calculation is being made from evidence accrued about what you want and how likely a given task is to get it for you, set against evidence of risk and consequences of failure. So all you have to do is find a way to make something seem more likely to get what you want, right?

Well, yes, except doing that is itself a task that requires initiation, which means it also gets stymied by next-steps that seem unclear or painful. It’s turtles all the way down.

But that’s not to say it’s hopeless; again, what frame you’re thinking of the problem in matters, as does real knowledge about what you want and how to get it, as do incentives.

So here are my practical suggestions, along with all the usual stuff like “reduce friction to doing what you want” and “set up good incentives” and “break tasks down” and “ask for help” and so on:

Suggestion 1: Distinguish what you actually want.

There are four things people confuse all the time, and use the same sort of language to express, despite them meaning very different things:

1) I want to do X.

2) I want X to be done, but don’t want to do it.

3) I want to be the sort of person who does or can do X.

4) I want to be seen as the sort of person who does or can do X.

It’s important to notice which of these actually applies to your circumstances, not just to better figure out what sorts of frames and evidence will motivate you to do it, but again to figure out whether it’s something you endorse trying to do at all.

(It’s also much easier not to beat yourself up over failing to be motivated to do something when you realize that you don’t actually want to, and realize what similar motivations might be crossed with the one you thought you were acting on.)

Always be clear whether priorities are guided by intrinsic or extrinsic motivation. I don’t have a source on this, but in my experience and from reports by others it is genuinely easier for a lot of students to do bullshit busy-work when the people asking them to do the bullshit work acknowledge it’s bullshit and take a “let’s just get through this together” approach rather than a “you’re a bad person if you don’t want to do this” one.

Suggestion 2: Review the actual costs/benefits.

Whether you’re journaling, Internal Double Cruxing, doing Narrative Therapy, or exploring Internal Family Systems, there’s something uniquely powerful about letting your thoughts finish.

Our brains are great at blocking or hiding from unpleasant thoughts. It’s basic behaviorism, reflexive as catching or flinching away from rapidly approaching objects. So when we need more evidence that something is worth doing to feel motivated to do it, we might keep the examination of that evidence from happening without even realizing it if the information comes “packaged” with painful thoughts or feelings.

You never know what might tip the amount of evidence your brain needs to do something past the initiation threshold, so one of the ways that we can “amass willpower” is by putting all the information in front of our System 2 and giving it time to process. This is part of why just talking to a friend about something difficult to do can make it easier, and we can isolate the effect by noticing a similar value from writing out the thoughts about it instead, or doing Focusing on some felt-sense of urgency, or giving space to internal parts to talk to each other. These can all provide different benefits, but what they have in common is that they’re time spent actually reviewing, sitting with, and absorbing the reasons why we want to do something, if you do, or why we’ll be glad that it’s done.

Let your inner sim slide forward in time, not just to the activity itself (which will likely make your attention focus on things that are fun to do moment to moment) but also to the post-act feeling, which may motivate you by focusing your attention more on the “completed a challenge” joy.

Suggestion 3: Prioritize smaller steps.

This planning/prioritizing stage can be a lengthy process or a nearly instantaneous one. Many have had the experience of feeling like they want to do something, or should do something, perfectly visualize what it would take to do it, but are simply/just unable to move their limbs.

In an extreme version of this, I heard from someone who reported that they needed to charge their phone, and the charger was even in reach, but the actual act of moving to get the charger felt insurmountable.

As a form of “break the task down into smaller steps,” I also suggest “prioritize smaller steps.” Don’t just break the task down into “turn off TV, get up, go to the computer, open email, select first unanswered email,” etc. That can be helpful sometimes, particularly for complex or obscure problems like research projects or bureaucratic paperwork, but it’s not priming the motivation generator.

Instead, also focus on how each step is itself valuable to you. You know the positive feelings you get sometimes when you stand up after being prone for a long time? You know how being in a sitting position for too long is bad for health? Let your attention focus on those things, and prioritize the task of just getting up first. You know that feeling of pleasure you get when you check something off a list, or remember that you made some progress on a task today? Focus on those feelings, and prioritize just opening the email and reading it if you haven’t, or starting the draft if you haven’t.

In other words, seek the positive valence attached to each step of an activity and focus on those to motivate you from one step to the next. If you’re having trouble feeling anything while doing this, note what your body sensations are as a default; if you feel numb in general, it’s going to be hard to feel motivated to do anything, since you won’t have an associated felt-sense (this is likely why depression and low-motivation are so correlated) and thus none of the things you imagine will help you reach the activation threshold.

In that case, do something to help you get re-embodied. For some people this is as simple as dancing; put on some music that makes you move, or just notice your body and feel your feet and sway your limbs. For others it means grounding yourself in your breathing or heartbeat, and expand outward from there.

Cheat Codes

I’m labeling these “cheats” without malice or judgment, simply because I have no plausible explanation for them beyond “they trick your brain into being in another state.” Even the word trick feels perhaps too judgmental, as it assumes that any other state you could change to needs to have some difficult or explicable process. Maybe it doesn’t/shouldn’t, and in any case, it seems worth noting these strategies in case they’re helpful, or to flag them as interesting things to explore in case others have models information to share about why they work they way they do.

Music: The right music can motivate you to do all sorts of stuff. This likely is related to the positive-valence thing; music can often shift your emotional state, and this is a valuable tool in many cases, such as when you want to exercise, or clean the house, or do something that feels scary. I claim a big part of this comes from narrative power, particularly as music from movies or games or anime seem unusually effective, but it’s not exclusive to those.

It’s hard to shift entirely from one emotional mood to a completely different one, so if this seems like it doesn’t work for you, one piece of further advice I have on this is to pick a song that evokes an emotional frame that’s in the direction you want to go while still being in the venn diagram of the one you feel. So if you’re sad, and you know playing a super bubbly, energetic, positive song just makes you feel worse, or can’t reach you at all… instead try a song that’s at least melancholy, but with a hopeful or nostalgic or bittersweet tinge to it.

Totems: Objects can change your mood too; clothing, teddy bears, pictures taped to your monitor, etc. Anything that alters or changes your state of mind can be a valuable tool for enhancing executive function. If you’re having trouble typing in that journal app you keep insisting to yourself you’re going to do, but wearing a bathrobe and writing in a physical book with a quill by candlelight seems more appealing to you, then go for it.

Frames: I claim that frames are, quite possibly, the most powerful and ubiquitous psychotechnology there is, but that’s a claim for a bigger post than this. Meanwhile, my assertion here is that they’re not just very powerful for motivation, but also possibly very dangerous if used in the “wrong way.” There are often many different frames that people can use to recontextualize or view the things they “have” or want to do, and it’s worth noting when the narrative you’re telling yourself isn’t working so you can explore what others might feel more true or reach that positive valence tipping point.

An easy example of this is how many people manage to work quite hard for long periods of time, day after day, because they believe it will advance their career if they do, compared to those who believe they’re working on something vitally important to the world or their values, compared to those who do because they believe there are people directly relying on them to. These are all things that can motivate different people in different ways, whether true or not… and also, all three can be true, but which one someone’s attention naturally focuses on in any given moment might not be the most motivating one.

Gamification: Adding an extra layer of incentives or accountability can be fairly motivating for many people, and may seem less of a cheat, since it can be obvious why it works, but there are some forms of this that still feel “mysterious” to me, such as the idea of a “winning streak” that many apps use to keep people motivated to keep doing something day after day without missing one, even with no extra tangible reward. For many people, being rewarded with recognition of our effort, even if it’s just pixels on a screen from a computerized process, can still affect our expected emotional valence enough that it can tip us over the motivation threshold when we might not otherwise do the thing.

Further Resources

The next parts of this series will cover the other 6 aspects of Executive Function:

Part 2: Emotional Control, Self Monitoring, Impulse Control

Part 3: Working Memory, Organization, Flexible Thinking

And there’s a video I’d recommend if you’re looking for another take on Executive Function. It breaks it down into three areas of the brain:

  1. Frontal-Striatal Circuit: Response suppression, Freedom from distraction, working memory, organization, planning. “What” network.
  2. Frontal-Cerebellar Circuit: Motor Coordination, timing/timeliness, “When” network.
  3. Frontal-Limbic Circuit: Emotional Dysfunction, Motivation deficits, hyper-impulsivity, aggression. “Why” network.

And offers its own list of practical advice with some overlap:

  • Reinforce yourself with rewards
  • Use verbal self-encouragement
  • Take 10 minute breaks between tasks
  • Frequent 3 minutes of relaxation/meditation throughout day
  • Visualize future benefits
  • Engage in routine exercise
  • Drink sugary drinks to keep your mental energy up

Edit: I’ve presented on this at a couple EAGs, one of which was recorded:

Therapy

Executive Dysfunction 101


First things first; “executive dysfunction” is not a diagnosis. Executive functions are what govern our ability to plan actions, take those actions, maintain focus on them, adapt to changes, and more subtle steps between.

ADHD is a diagnosis that points to a cluster of common struggles with executive function: working memory, impulse control, and self monitoring. But there are plenty of other diagnoses that can impact one or more of those eight, and of course even things like lack of sleep, hunger, being irritated, disruptive environments, and other stressors can affect them.

So in general when we talk about executive dysfunction what we’re really pointing at is a symptom we witness when someone isn’t able to act on their desires, or on things they think they should do, or on things they think they should desire.

Which brings up the more philosophical question; what does it mean to “fail to act” on a desire? Does someone “have executive dysfunction” if they struggle to complete something they don’t want to do, but feel they have to? What about what they “want to want” to do, but don’t find interesting, even while they can still work on passion projects without issue? Or is it only executive dysfunction if they can’t bring themselves to work on something they feel a strong desire to do, in which case what does “strong desire” mean?

All this makes the question of whether someone struggles with executive dysfunction ill-posed. The better question is “in what domains or in what types of circumstances does someone struggle with executive dysfunction,” followed by narrowing down to which of their executive functions are the chokepoint. Organization? Task initiation? Emotional control?

(I’m also not a fan of “emotional control” as a phrase, as it implies something like stifling or dampening or wrestling with your emotions. This might accurately describe the feeling for some people, but integrating emotions in a healthy way doesn’t have to feel like any of that)

With this more precise understanding, the possible interventions also become more clear. Organization and planning skills can be learned, as can self-awareness and emotional integration. Multitasking and working memory, meanwhile, are harder to improve, and so reducing distractions by adjusting the environment might be more effective.

But most importantly, the question of whether the task is tied to a “want” or a “want to want” or a “should” can itself guide people to better understanding whether their struggle is one that is worth resolving at all, as compared to one that isn’t worth the costs compared to other actions or paths. Many people have pushed through some difficult job or university degree and were glad they did; others regret time wasted and emotional suffering endured for a goal that didn’t end up mattering to them.

Which is why executive dysfunction should not be treated by default as a difficulty that needs to be overcome. Instead it can also be a signal from one or more of your parts that the path you’re on is not the right one for you, and that you might benefit from searching for other, better roads, or even goals.

Along with depression and anxiety, additional factors can exacerbate executive dysfunction, such as perfectionism. The idea that anything tried must succeed, or be done perfectly, often leads to a feeling of dread or hopelessness at the prospect of even starting a task. This is particularly exacerbated by OCD.

Which leads to a general theory of treatment that includes things like exploring motivations and dissolving “shoulds” as a first step before taking for granted that failure to do something is about the person rather than the thing they’re trying to do.

Once that’s done, only then is it useful to focus on strategies for breaking tasks down into simpler versions of themselves, finding tools and contexts for improving focus and accountability, and generally working around that colorful circle up there as much as possible to improve all the ways executive functions might be disrupted. For example, since past difficulties can exacerbate this sense of predicted suffering or failure, it’s also important to focus on small, achievable steps that are more likely to succeed and thus increase predictability of success.

[The above refers to the parts model of the self, and to the therapeutic idea of systematically replacing the concept “should” with less normative framings. A lot of people find these helpful, but they’re not consensus views and they don’t work for everyone.]

To further explore this, I plan to write a series of posts on how to procedurally explore executive function within ourselves so that we can identify the places where we get stuck when we have trouble doing stuff we want to do, and have a better idea of what can help.

Procedural Executive Function: Part 1

Procedural Executive Function: Part 2

Procedural Executive Function: Part 3

Therapy

Journaling 101


I often get asked what the most things valuable things people can do to improve their mental health are, and while it’s really hard to give a general answer to that sort of thing, what immediately always pops into my mind is journaling.

Journaling is almost the physical exercise of the mental health world; something uncomplicated and risk free that most people would benefit from doing more of. The reason it’s not is that physical exercise is also the physical exercise of the mental health world.

But there more similarities; even just a little bit tends to be significantly better than none, the kind you do doesn’t truly matter that much, and people are more likely to do it if they don’t have an expectation that there’s one specific kind (that they don’t like) that they’re supposed to do.

Personally, I hate running, but I love to swim. I get bored with stationary bikes or lifting weights unless I’m watching anime at the same time, but VR has been a fantastic way to get your heart pumping while having fun.

Similarly, I want people to know what their options are, so that when people think “maybe I should try journaling,” or are told to by their therapist,  they know there are a variety of different ways to do it, and know not give up just because the first they try doesn’t feel good.

So here’s a handful of ways to journal that clients have found helpful:

  1. Recounting Your Day

This is the most basic and stereotypical form of journaling, where you just write out what happened that day that was noteworthy, and maybe some thoughts or questions or worries that came up. Nothing wrong with it, but many find it a difficult or boring.

2. Stream of Consciousness

Less structured than the previous form of journaling, this is literally just writing whatever comes to mind.  It doesn’t matter if it feels “relevant” or “important” at all, it could be fiction, it could be pure sensory input, it could be anything. It’s just about creating space to sit with your thoughts and let them flow. You might be surprised at what comes out.

3. Scaling Your Day

This is the minimal viable product for journaling. Scaling how your day felt, either -5 to 5, or 0 to 10, with the lowest being “genuinely wanted to die” and the highest being being “life felt perfect,” can be useful even if you don’t accompany the number with any words (although you always can, of course). It sets a baseline that can be useful when you want to check if thigs start to change in a positive or negative direction, and also can be valuable for noticing large spikes up or down compared to previous days, which are sometimes hard to notice in the moment. But again, the value of even this sort of journaling can come from simply taking the moment to reflect on your day.

4. Gratitude Journaling

This is another really popular and common form of journaling that often surprises people with how much value they get out of it. You can write about people in your life that you’re grateful for, or things about yourself, or things in the world like puppies and books, or all of the above. You can do a simple 3 bullet list every morning, or write a paragraph about one thing every night. The idea is to generally spend more time thinking about positive things.

5. Letter to Future You

Many people have found that framing their writing as if to someone specific often unblocks the process for them, whether it’s to explain some technical bit of knowledge or just to explore their own thoughts and feelings. Writing your journal as a series of letters for the next-day-you can be valuable in this way, but also helps frame the content in a useful way too; what do you want to yourself to remember tomorrow? Not in a “to do list” way, though obviously you can include that stuff if you want. This is more about what sorts of emotional states you want future you to retain, and it can lead to some interesting chains between the various yous throughout your week or month as the conversation baton is passed along one day to the next.

There are plenty of other journaling methods, but this is the shortlist that I tend to recommend to clients, and usually they’ll find at least one of them appealing and valuable. Basic habit setting advice applies; set an alarm, keep your journal by your bed (or just use a phone if that’s easier), accountability apps, etc. If you have a romantic partner, maybe it’s something you can do together.  If you’re on twitter, try tweeting the things you’re grateful for and see how it feels.

Also, don’t feel a need to actually write if you hate writing or typing; Even just talking out loud to yourself is better than nothing, and definitely adds an extra element to “letter to future you.”

Therapy

Emotional/IFS Integration 102


(This is going to be another brief + tips oriented review of IFS concepts; be sure to read the 101 post if you’re totally new to this)

Not all parts that can exist inside you are naturally there or equally fleshed out. Circumstances in life will strengthen one or another, but like the saying about the two wolves inside us, you can also intentionally “feed” specific parts to make them stronger, and there’s one part in particular that your whole system will benefit from having strong.

Some call it the Ideal Parent Figure, others the Ideal Future Self, Inner Champion, Inner Mentor, etc. By some interpretations these could be considered “guides” or “critters” or “voices” rather than parts, in that they may speak to you but not want to act on their own, but that might vary per person. Additionally, their roles are subtly different based on the internal system they’re part of, but are still broadly those of Mediator, Comforter, and Encourager, whose primary value is their endless compassion for you and your parts.

Self-compassion is crucial to IFS, not as a prerequisite but as the primary ingredient for true acceptance of your parts/emotions, productive forgiveness for your mistakes, and a dignity that no one and nothing in life can take away from you. When you unconditionally love yourself, all sorts of healing and growth become possible, and you can create much stronger boundaries between yourself and harm.

Developing and feeding these inner parts can look similar, but experimentation can help find which works best for you. For this post I’ll just give brief advice for the first two:

Ideal Parent Figure is often a source of compassionate mediation between your parts. It helps you bring the Exiles in from the cold, soothe Anxiety’s fear of being ignored, understand Anger’s justifications, relax Firefighters’ vigilance, etc. Those who had abusive or distant parents often don’t know where to start with constructing this, unless they’re lucky enough to have met a friend’s parent or other mentor in their life who can serve as a model. Fictional characters can work too; Mr. Rogers is an example of someone widely considered a “platonic parental figure,” and many have found comfort and self-compassion by internalizing his “voice” and perspective to help replace some of the more harmful self-talk and their own (often well intentioned) imperfect parents left them with. You can also use this Protocol to help visualize what having a part like this could actually look like.

Ideal Future Self in many internal systems (my own included) serves identical purposes to the IPF; it’s particularly useful for those who had no sense of “parents” as a distinct emotional category, positive or negative, by instead drawing directly on your aspirations. Constructing and feeding your Ideal Future Self is done by thinking over and writing out what a version of you with all the skill and wisdom that you hope to develop would say if they were around and freely able to give it to you, all in a compassionate way. Your ideal self would not judge any shortcomings and failings you have, because they remember your journey and all the difficulties you struggled with along the way. They serve less often as the mediator for your other parts (those without “parent” as emotional category are more likely to act as their own internal mediator), and more a source of encouragement for you; they believe in you, and care about you, and are waiting for you, no matter how long it takes. This means that you can also develop them by writing to your past self, and telling them what you wish someone had told you, particularly in your darkest moments. Like with the IPF, it can often be very healing to deliberately imagine yourself hugging your past self as you deliver the words, and similarly imagine your future self using soothing touch as they comfort and encourages you.

Psychologically, whatever this part is called, it acts as a container for all the things you intellectually might believe, but still have trouble emotionally accessing at all times, particularly at your low points.  Samples of the sorts of things they would often say include:

  • “You don’t have to be perfect to deserve love and kindness.”
  • “I know it’s hard, but I’m proud of the progress you’re making.”
  • “There’s nothing wrong with your wants/feelings, even if they’re confusing.”
  • “You made a mistake, but it doesn’t have to define you.”
  • “You can get through this. I believe in you.”
  • “It’s okay to hurt. I’m here. We’ll get through this together.”

It’s okay if you don’t believe these just yet, or if there are other voices shouting the opposite. The purpose of taking time to better build up these models and strengthen these parts is to help make these feel more real, particularly if you have memories of times they did feel true and spend time meditating on those experiences.

Once these parts are solid enough, they make practically every other aspect of emotional integration easier. It’s quite literally like having a perfect ally travel everywhere with you, ready and waiting to step in and help you whenever you need a steadying hand and comforting word.

(For further reading, here’s a good overview for why self-love and self-compassion is so powerful, with more good resources at the end.)

Therapy

Emotional/IFS Integration 101:


(The following is my own understanding and practice of IFS, and may include elements that conflict with the standard model. In an attempt to keep these brief I won’t be going into much theory, and focus on what seems to work best for myself and my clients)

Internal Family Systems is a form of therapy that treats psychological or emotional difficulty as the result of disagreements between the “parts” that make you who you are. Sometimes these parts make themselves known as (disagreeing/discordant) thoughts, other times as (conflicting/painful) emotions. A variety of labels can be useful to identify and understand their effects and interactions; in the classic model, these are Exiles, Firefighters, and Managers, as well as the Self, which is the “part” that your conscious mind remains associated with even amidst fragmentation.

But there are many forms IFS can take, or layers that can be applied onto each other. For some, characterizing their parts as actual family members (Child, Teenager, Adult) is very useful. For others, a starship crew (Security, Engineering, Science, Captain) makes for easier internal communication. Whatever form these parts take, IFS can be valuable for many purposes, but the most straightforward one is simple “emotional integration,” which is to say, conversely, feeling more like a unified individual rather than struggling with emotional turmoil over some looming decision or past action.

The path to integration looks something like this:

Acknowledge->Identify->Accept->Manage->Integrate

This is not always linear progression, as emotions and parts might shift or grow nuanced over time. It’s also uneven; you can have one emotion Integrated, while struggling to Accept another and having trouble Identifying a third.
 
Most people who struggle with emotions/parts are either trying to skip ahead, or mistakenly believe they have succeeded at one step before they actually have. It’s also not always fully in our control. It can take time to process things, particularly traumatic things, and that’s okay.
 
There are skills that help with each. Meditation and mindfulness techniques help with Acknowledging. Gendlin Focusing helps with Identifying. Eliminating “shoulds” helps with Acceptance. Note that eliminating “shoulds” includes eliminating “shouldn’ts.” Parts are what they are, even if confused/traumatized. Healing starts with compassion toward your part, or yourself for having it.
 
(This can, admittedly, be tricky if those shoulds and shouldn’ts feel like they’re coming from other parts! But your “core self” can then differentiate itself from the part that’s expressing the should, and accept both parts, the same way writers learn to harness their inner critic rather than silence or be cowed by it.)
 
Learning conflict mediation helps with Managing, whether you act as the Mediator between your parts or one of parts takes on that role. Systems theory, cybernetics, NVC, reflective listening, double crux, all that fun stuff are useful here. Again, these are learnable skills, and it doesn’t take much more work to apply them to your parts instead of other people; just extra imagination and honesty and self-compassion.
 

Finally, Integration comes from practice, patience, and trust. As I said, it’s not always a steady progression. We encounter new things, life gets messy, parts get out of sync. But trust yourself, be patient with yourself, practice the skills, and the rest of you will be ready and waiting to re-integrate until you feel like unified again.

(You can learn more about IFS from this more in-depth article)

Therapy

The Bad Therapist


I often think about what makes a good therapist, and find it a hard question to answer in an organized and concise way. What’s far easier, and maybe as helpful to anyone looking for therapy, is the reverse question. So, in the style of CGP Grey’s 7 Ways to Maximize Misery, I hope this list of what makes for a bad therapist can help you find a good one.

  1. A bad therapist lacks all curiosity.

They assume that their education or experience or inherent wisdom means they just know what the client means and wants and needs, even if (sometimes especially if) the client disagrees. They rarely use reflective listening or Socratic questioning, and rather than reserving assertions for psychoeducation and normalizing, instead tell the client precisely what they think is wrong, what mistakes the client is making, and/or what the client needs to do to improve, all stated with confidence rather than as hypotheses. And if your therapist does all this within the first session? Run away.

  1. A bad therapist will not respond well to negative feedback.

They expect their therapy style and modality to be perfectly suited to any client, and are not willing to adapt or learn how to best help their client. This isn’t to say all therapists and clients are suited to each other, but if reports of dissatisfaction are  turned back on you with accusations of projection or “resistance to treatment,” that’s a great red flag to find another therapist.

  1. A bad therapist pathologizes constantly.

Anything unusual about the client, from their hobbies to their fetishes to their philosophy, is suspected of causing dysfunction regardless of whether it actually does. These therapists conform to the broader culture they’re embedded in, and act as agents of social control on all manner of moral issues, from sexuality to family dynamics to choice of profession. If your therapist speaks in clichés such as “Family always forgives” or “Marriage is a sacred bond,” find a more open minded one.  

  1. A bad therapist shames their client, or makes them ashamed of themselves.

Guilt can be a powerful generator for change, but a therapist’s role is to gently guide the client to better understand themselves, and the sometimes complex relationship between what we value and what we do. If your therapist demonizes your thoughts or feelings or desires rather than helping you better understand them, you’re dealing with another therapist too trapped in their culture or biases to properly facilitate lasting healing and growth.

  1. A bad therapist pushes their worldview onto the client. 

A religious therapist who insists that “God works in mysterious ways,” or an atheist who dismisses spiritual comforts are not only unlikely to help their grieving client of the opposite beliefs, but can cause extra harm by making them feel alienated and unheard. Finding a therapist who matches your worldview can be valuable, but any competent therapist should be able to leave theirs (mostly) at the door.

  1. A bad therapist can’t remain objective. 

Early signs of this may be a therapist who talks too much about themselves or seems overwhelmed by their client’s problems. More subtly, therapists can struggle not to triangulate with a parent or child or spouse against child or parent or spouse. It may even seem like a positive, if for example the therapist starts to seem like a friend who constantly comforts and “takes your side” in everything . To be clear, objective doesn’t mean perfectly balanced; sometimes objectivity requires helping us understand when a mistake is one-sided. But if you don’t feel like your therapist is making an effort to include everyone’s perspectives, find another one. 

  1. A bad therapist will insist that their model is the only one with value.

These therapists view all of mental health through a single lens, the causes and solutions to illness forced into the mold they developed during their education or personal experiences. While an expert in a specific modality can be invaluable, a professional should always be ready to refer a client elsewhere if they encounter a problem in treatment, rather than blame the client and insist they’re not understanding or not trying hard enough. 

  1. A bad therapist is okay with therapy lasting forever.

I may be being too normative here, but I think it’s suboptimal for a therapist to make no effort to set concrete goals or give the client the tools they need to move on without them. This doesn’t mean therapists will know how long a problem “should take,” which we get asked all the time. But after a few sessions, you should have a sense of what it would take for you to feel satisfied ending therapy, or at least reduce the frequency of sessions. If you don’t, it’s worth bringing it up with your therapist to see if the therapist has a sense of direction or goals in mind. Subjective goals and estimates are fine, and many therapists will be wary of overpromising. But ideally there would still be some observable change in the client’s life that they can use as a metric of growth.  It’s also fine to go back to therapy every so often as needed; it’s just the unending years of weekly therapy that, to me, indicates something suboptimal is going on.

  1. A bad therapist can’t properly balance uncertainty and responsibility. 

This is the kind of therapist who attempts to hospitalize their client due to non-critical self-harm, or for simply talking about their suicidality, rather than because there is imminent and specific threat to life. Unfortunately there is little you can do to predict that your therapist is like this ahead of time, but you can at least get a sense for how well they understand the limits of confidentiality when they explain it to you; a good therapist should clarify this distinction so their client feels safe being open about how they feel.

  1. They think therapy is about talking, not doing.

Maybe too normative of me again, but while a large part of therapy is talking, it’s been a century since Freud borrowed the phrase “Talking Cure” and ran with a model of therapy aiming purely for catharsis. I think therapy should be doing more than just venting and processing; it should also involve learning new tools to be practiced between sessions, so that you can reach a point where the therapist is no longer needed. To be clear I’m thinking in terms of suggestions rather than strict “homework,” and some clients may prefer not having even those. But if you feel like therapy isn’t doing much for you and yours hasn’t suggested things for you to do between sessions, start asking for some.

I hope people find this helpful; as I said, it’s not a great guide to help finding a good therapist, but I’ve heard enough horror stories in my professional life by this point to at least try to minimize the amount of bad ones people waste their time, money, and emotional energy with.

I should also clarify that while I hesitate to label anyone a “bad therapists” by some of these more than others, I think each of them does drastically limit the amount of people and situations a therapist can help. For example, therapists who are stuck in a certain cultural zeitgeist can still help clients who conform to that culture’s norms, and therapists who never plan to discharge clients can also still be beneficial to them; hopefully that’s why the client would keep going!

But in my experience at least, each of these represent real failure modes in the therapeutic process that can end up causing more harm than good.

Additionally, it’s worth emphasizing that, independent from how good a therapist is, the most important part of any therapeutic relationship is the individual rapport between client and therapist.  It doesn’t matter what philosophy they have or how they orient to things like how long therapy should be if it doesn’t feel like a good match. If you don’t trust your therapist within the first few sessions, if you don’t feel comfortable talking freely with them, it’s probably better to just find a new one.

As a final note, I deliberately avoided mentioning anything that would count as a violation of therapeutic ethics and professional norms. If your therapist breaks confidentiality, tries to date you, regularly misses sessions, etc, the label “bad therapist” is no longer sufficient; at that point they shouldn’t be a therapist at all, and should be reported to their licensing body.

Therapy

Philosophy of Therapy


For a lot of people, therapy can be a confusing, mysterious thing of questionable value. Many have tried it when they were younger, and felt that at best it was only of minimal help, while for others it actually made things worse. In many cultures, therapy looks very different from how it’s practiced in the “western world,” and the concept of mental health itself is often treated with suspicion or dismissal. I’ve known many people who, even while not being skeptical, were still confused about what the purpose of therapy actually is, or what situations warrant seeking a therapist out.

In my practice as a therapist, I often reorient myself to the basic core of therapy, which to me is about helping people get unstuck. Sometimes the thing you’re stuck on is a recurring and disruptive emotional state, other times it’s some harmful interpersonal dynamic, and other times it’s a pattern of behavior. Whatever the specifics, there is some aspect of the client’s life that is not going the way they would prefer, and the therapist’s job is to help them find a way to change that.

What the therapy provides also varies; good therapy can create space for honest expressions of emotion, provide new perspectives or insight, and offer new “tools” for the client to use in their lives, specific behaviors or mental motions that help move past the stuckness.

Those skeptical of therapy often wonder: can’t people just talk to their friends or family if they need emotional support? Aren’t there self-help books they can try? And of course they can, and should try those things! For many people, the majority of their difficulties do not require a therapist.

Which means therapy is for what’s left. Those things that seem truly intractable, the things that you feel stuck on, which other resources have failed to help resolve.

But I’d like to demystify therapy further, and better yet, I think by better understanding what therapy is meant to do and how, people can get some of the value that therapy can provide even without going to see a therapist.

Because while a good therapeutic relationship is the best predictor of change (which is why first finding a therapist that you feel comfortable with is at least half the battle), for a large portion of clients I’ve seen, even just changing the frame of the problems they experience, or changing the way they view themselves in relation to their problems, actually makes the problem less sticky. A new frame can reveal not just a path to wellness, which is vital for those who are nearly hopeless, but also more levers to pull and knobs to turn,  new vistas of the mind to explore and inhabit, that can help make the problem more manageable.

So that’s the goal of this essay. By teaching the history of the different philosophies of therapy, I want to teach you how changing the frame can change the problem.

I. History

Ask people to describe what therapy involves or “looks like,” and most who haven’t been in therapy will say something like “one person lies down on a couch and talks to the therapist, who takes notes and asks questions like ‘How does that make you feel’ and ‘Tell me about your childhood’ and ‘How do you feel about your mother?’”

This is largely the result of Hollywood Therapy, but it’s rooted in the origins of therapy, which is Freudian—what’s now called Psychoanalytic Therapy.

Sigmund Freud was the progenitor of applied psychology; the idea that we could study the way people think and feel and act, and use it to directly help them “improve” in some way. He was inspired by his mentor, a physician who helped alleviate a patient’s untreatable illness by just asking questions about her symptoms. That patient coined the term “talking cure,” and Freud took this concept and ran with it, dedicating his life to the idea that many ills people suffer are psychological in nature rather than physiological, and that just talking about them can help reduce or remove them.

Freud had a lot of ideas of his own, however, and while many them turned out to be nonsense, he also had some that turned out to be true, or at the very least, useful, such as the concept of a “subconscious,” or the idea of dividing a person’s mind into subagents (in his case, Id, Ego, and Superego). As the arrow above indicates, Freud cared almost exclusively about the past; he believed that by studying one’s childhood, the way they were raised, their early environment, or the origin of a certain dysfunctional behavior, you could identify all sorts of traumas or stresses that cause dysfunction later in life. Once identified, he believed the client would gain a feeling of “catharsis” that would start the path to healing.

Here’s where I admit that I have something of a bias against psychoanalysis.

In my view, Freud was a philosopher first and foremost, rather than a scientist. He had interesting ideas that seemed logical to him, and a scientific frame of mind, but while he pursued the application of these ideas with an admirable gusto, his documentation did not seem to aim its rigor at testing which of his ideas were true. I’m unaware of any hypotheses Freud generated that he then went on to falsify. (If you know of any, please do share them!)

Far from an attempt to bash the man, I do admire him a great deal. It’s hard to be the first person to basically invent an entire field of science and do it all perfectly such that you are simultaneously the person observing reality, coming up with ideas, and dispassionately testing those ideas, all while trying to do work as a clinician. But I believe most modern schools of therapy have picked out the gems of his work and left the rest to history lessons.

That isn’t to say this branch of therapy is all worthless. While catharsis alone generally doesn’t solve most people’s symptoms (psychosomatic illnesses like his mentor’s patient’s are in fact very rare), delving into one’s past can lead to insights into their current problems, and many do report feeling better about their problems when they have a chance to talk about them (again, credit to Freud, this would likely have been very encouraging to him when he began his work).

Additionally, as a colleague pointed out to me after reading an earlier version of this article, many modern psychoanalysts do seek to empirically test the field’s ideas in order to continue to develop evidence-based treatments, and modalities such as Transference-Focused Psychotherapy have evidence suggesting it to be at least as effective as other standards of treatment.

(A modality is a method of therapy that has a specific structure to help a client reach wellness. More than a specific intervention, modalities often include multiple interventions, as well as a particular type of relationship between client and therapist that dictates whether the therapist acts as more of a guide, partner, or authority. Each modality operates on a particular hypothesis of how therapy can help clients with certain problems.)

In any case, while psychoanalysis as practiced by Freud and his ideological descendants (Carl Jung, Anna Freud, Erik Erikson) focused so much on the client’s past, new discoveries in psychology led to therapeutic modalities that focused instead on influencing the client’s future.

Enter, the Behaviorists.

As Freud is to Psychoanalysis, so Ivan Pavlov, of dog fame, is to Behaviorism. Pavlov discovered and experimented with classical conditioning, the idea that you can pair different stimuli to influence responses. This discovery was a great boon to pet owners, but also has direct applications to therapy. One example is addiction treatment, where for example the sight or smell of cigarettes or beer is paired with something that will evoke disgust. It also led to desensitization therapy for phobias, where pairing progressively more frightening stimuli with techniques and context that help relax the client can alleviate the fear response.

These ideas were expanded by Edward Thorndike and B.F. Skinner, whose work is called operant (or instrumental) conditioning. Rather than just pairing stimuli together to affect responses, their experiments showed demonstrable effects on learning and behavior through reinforcement and punishment; in therapy the idea of using positive reinforcement to incentivize desired behavior is often helpful for children, particularly those with developmental issues.

I don’t have much to say about Behaviorism. For some things that people come to therapy for help with, it just works. For others… not so much. I think understanding the mechanisms of Behavioral Therapy is valuable for any clinician, but there’s some obvious flaws with taking it as the only avenue toward better mental health.

Unlike psychoanalysts, a straw-Behaviorist doesn’t care about your past, and talking about your traumas or “deeper issues” would often be considered a waste of time. Instead the focus is on your symptoms. No symptom, no problem, right? Just apply the right type of reinforcement to increase positive behaviors and the right type of punishment to decrease negative behaviors, and all’s well…

…for some people, at least. Behaviorists had a lot of success in some domains, particularly when the “why” of the problem didn’t actually matter to the client or issue, but obviously struggled with others. After the first World War, clinicians formally recognized PTSD, or “shell shock,” for the first time. Unfortunately, attempts to treat soldiers through psychoanalytic and behavioral therapy often failed, and so many psychologists turned clinician to help figure out how better understanding the present feelings we have, and how they impact our behavior, can lead to mental health.

Which brings us to Existential Therapy.

Rather than having a single founder, the Existential philosophy of therapy was converged upon by a wide range of psychologists and clinicians, many inspired by the writings of Kierkegaard, Nietzsche, Husserl, Scheler, Heidegger, and Sartre. These writers’ attempts to redefine our understanding of not just what it means to be human, but an “actualized” human, a healthy, thriving, happy human, were believed to have great value in clinical efforts to help those in need.

But among that foundational pantheon, the first of the Existential therapists was Otto Rank, a student of Freud who later split with him over Freud’s beliefs that a person’s “formative years” are what determine who they become. Instead, Rank believed that human development continues throughout our lives, requiring continual negotiation and renegotiation between dual yearnings for individuation and connection.

For such heresy he was excommunicated by the psychoanalytic world, but he nevertheless influenced his own “family” of psychologists, including Rollo May, Viktor Frankl, who’s more well known as the author of Man’s Search for Meaning, and Abraham Maslow, of hierarchy fame. These psychologists focused not so much on what happened in someone’s past or how to influence their future, but on their now. What do people feel like they need, that they lack? How does the client experience “need” at all? What relationship do they have with their hurts and wants, and what would be necessary for them to feel fulfilled? How do those different needs and wants conflict with each other, and how can they be better brought into harmony?

Existential therapy also marked a new dynamic between client and therapist; rather than a top-down hierarchy, where the clinician is the “expert” and the client the “patient,” what became known as client-centered therapeutic practice began to form. It placed both therapist and client as equals; the clinician has the education and skills, but the client is the expert on their own lives, of what they think and feel, and so the Existential therapist’s role is more that of a facilitator to the client’s growth.

This may seem like polite semantics, but most people who’ve been to both kinds of therapists can tell how big a difference it makes if, upon disagreeing with their therapist on something, they’re treated not like a stubborn mule who is “resistant” to change, but rather a person with agency, whose motivation to improve is taken for granted by their therapist. The philosophy also emphasizes the importance of a therapist who is willing to listen, encourage, and support the client’s personal journey to better mental and emotional health, as the client defines those things.

Under the light of Existential Therapy (and its more upbeat twin, Humanistic Therapy) there grew many techniques to help clients better understand themselves, including Carl Rogers’s “reflective listening,” which has become a staple of good therapy from every philosophy, as well as techniques to better interface with our emotions, such as “focusing” by Eugene Gendlin, which I personally have found to be one of the most generically effective tools to teach practically every client I’ve had.

Time to admit to another bias, in case it’s not clear; I’m a huge fan of existential/humanistic therapy. In my experience it has a wide “range” in what it can successfully treat, and its frame makes up an integral part of what makes modalities effective in general.

But it’s not the form of therapy I was formally educated in, and it’s not the latest form of therapy that was developed. There’s one last dimension that even existential therapists failed to engage in, and if you’re following the theme of the arrows you might have guessed it: the opposite of focusing on ourselves is focusing on everything else.

Enter Systemic Therapy (also known as Family Systems Therapy, or just Family Therapy), born in the 1950s from a very powerful need; the need for better marriage counseling.

In the post WWII era, if a husband and wife wanted to save their marriage, they would go about it thusly: the man would have his counselor, and the woman would have her counselor, and both would see their counselors separately. If they went to a fancy clinic dedicated to marriage counseling, the two clinicians would be coworkers, seeing their clients individually, then consulting on the case between sessions, or even mid-session before returning to their clients.

If that sounds crazy, just remember that this was the 50’s, when people still thought smoking was good for you. The idea was that a client’s relationship with their therapist was sacrosanct, and must always be preserved as a space of utter one-on-one privacy that would allow them to be completely frank, without worrying about their spouse’s presence, or their therapist telling their spouse anything spoken of in confidence.

Eventually some therapists in California realized how absurd this was, not to mention ineffective. They suggested a new way to practice marriage counseling, where a single counselor (or even two) spoke with both clients together, in the same room and at the same time. That way a therapist could observe their interactions and mediate their discussions directly.

Their clinic said no.

So Don Jackson and his colleagues left to form the Mental Research Institute in Palo Alto, where they developed their own modality of therapy, one that involved not just the individual patient, but sometimes romantic partners, family members, even friends if the problem called for it.

They weren’t the only ones; Alfred Adler, Salvador Minuchin, Murray Bowen, Ivan Boszormenyi-Nagy, Virginia Satir, and Jay Haley all developed modalities based on the idea that, to help a client overcome dysfunction, the therapist should focus not just on the client, but the system they’re a part of, whether that be their family, their work environment, their culture, or even their country, all at various levels of abstraction.

(There isn’t going to be a test on all the names I’m throwing at you, but if I went into every single modality we’d be here all day, and this way you have an easy way to look into them on your own if you want.)

The study of cybernetics and communication theory were also prominent influences, particularly by the anthropologist Gregory Bateson, who believed that all forms of communication are adaptive, and rejected the concepts of linear and dualistic thinking for studying systems. 

 The “systems” being referred to in these therapies can be any context you’re a part of, individually or simultaneously: family system, school system, work, friend-group, even cultural and religious. According to Bateson, being part of any system leads to  inherent and unavoidable communication between you and the other parts, implicit or explicit, which affects the other parts of the system and how they behave, which further affects how you behave, and so on. Additionally, there can be no divide between an interactive observer and participant of a system; by observing the system directly, the therapist becomes a part of it.

This understanding led to a philosophy that takes the humility of existential therapy even further,  and improved clinicians’ ability to map the impact of one part of a system on the others, such that many modalities do not even identify anyone in particular as “sick” or “healthy,” but rather views behavior patterns themselves as dynamic or stagnant, and focuses on how change can propagate through the system by nudging elements of it. By understanding how everyone’s actions and reactions affect each other’s behavior, the client and clinician have more surface area on the problem to try and find solutions, more levers to pull and handles to grip from.

A big reason why this lens can be so valuable is that when you start working with groups rather than individuals, you have to address the fact that often times, not everyone involved in therapy has the same desire to be there, let alone incentive or drive to change. Of course, that was true before couples or entire families were being invited into a therapy room at once, but now the therapists were actively working to address it rather than just assuring whoever cared enough to be in the room that the problem was other people, and not them.

Oh, also worth noting that therapy up to this point was still a LONG process, often expected to last years. Systemic Therapy made a push toward briefer, more effective interventions, creating modalities like Solution Focused Therapy, which combined Systemic and Behavioral principles to bring about real, lasting change within 4-6 months.

So, that’s the four cardinal philosophies I’ve sort-of-made-up as a labeling scheme to map all therapy onto. Now we get to the meat of the matter; how can just knowing about them actually help?

II. Case Study

“You have to help me,” Marge, 55, says during her first session. “It’s my husband. He’s become obsessed with model trains!”

Sidebar 1: An important thing to note is that the client said she needs help, but highlighted her husband as the focus of therapy. Some equivalent of “fix my spouse” (or “fix my kid”) is nearly as common, in my experience as “fix me,” and often times the spouses in question aren’t always in the room. So we work with what we have.

“I can see you’re worried about him,” I say. “What does ‘obsessed’ look like? Are you running out of money?”

“Well, no,” she admits. “We can afford it, but… every month he’ll order hundreds of dollars worth of new models and tracks, and after work he goes down to the basement. He spends hours down there, every day!”

I nod. “Yeah, it makes sense why that might be concerning. Is he skipping meals? Staying up all night?”

“No, no. He’s sleeping fine, he’s still eating… but it’s quick, you know, he’ll pop out of the basement for ten minutes, wolf down his food without looking at it, then go back to his trains for another six hours. That’s not normal, right?”

Sidebar 2: “ Normal,” along with “healthy,” is perhaps the most loaded word in therapy. Unless the client is insistent, or we’ve formed a strong therapeutic relationship, I try to avoid giving any kind of verdict on either, and instead use the therapist standby of answering a question with a question; in this case not ‘what is normal,’ but rather:

“What would you consider to be the ‘normal’ things he does do?”

“You mean like work?”

“Yeah, and beyond that. Is he still seeing his friends?”

“Yes, once in a while he’ll go out for some drinks with them.”

This is evidence that he’s not a shut-in. “Feel free to say it’s too personal for now, but just to check, does he still want sex?”

She blushes. “Not often, but, yes. Sometimes.”

“Okay. Does he talk about other things, or is it all trains all the time, now?”

“We barely talk at all, now, not like we used to.”

“What was the last conversation you had with him?”

“Oh, about the kids.”

“You have children?”

She smiles for the first time. “Yes, two. Both married, one with our first grandchild on the way.”

“Congratulations! And he’s still interested in them, and the grandchild?”

“Oh, yes. He put off our vacation so we’d be around the first few months.” Her smile is gone now. “Which normally I’d be in favor of too, but… there’s some sort of convention nearby around then that he’s still planning to go to.”

“A model train convention?” I guess.

“Yes, I’m telling you, he’s just…” She shakes her head, seemingly at a loss for words.

Sidebar 3: “Pathologizing” is the perception that any action or view that is unusual is automatically a sign of illness, despite no evident dysfunction or suffering. In decades past, previous versions of the Diagnostic and Statistics Manual labeled things like homosexuality a mental health illness due to a mentality that didn’t distinguish between “normal” and “healthy.” Newer versions of the DSM have eliminated most of those, and there’s a concerted effort among (good) psychologists and therapists to distinguish real pathology as something that causes direct suffering for the patient.

At this point, I might feel an urge to say “Okay, so… what exactly is the problem here? Just because your husband is spending hundreds of dollars and hours a month on model trains doesn’t mean he needs therapy. If it’s not affecting his sleep, or his appetite, or his work, or his social life… maybe he just likes trains, and that’s okay? It’s far from the worst hobby, and if it makes him happy, just let him like trains!”

I wouldn’t say this out loud, however, at least not in the first session, because even if I’ve become at least reasonably sure that the husband is okay, to say something like that would be dismissive of her experiences .

Regardless of what her husband is doing, she is clearly unhappy. And while she might think she can be the client but not the patient, the truth is, from a systemic lens, there is no distinction. The system she lives in, her marriage, is clearly dysfunctional for her in some way, as evidenced by how she’s suffering enough to come to a therapist. Perhaps her husband is too, in a non-obvious way that will be revealed through further questioning, but for now the focus would best be shifted to her.

There are a number of lenses through which to focus, however, and each might approach the problem in such different ways that they essentially become different problems .

  • A psychoanalytic therapist could delve into Marge’s past. Was her father distant with her, perhaps obsessed with his work or a hobby of his own? Did she have older siblings that left her out of their play? Was a childhood friend killed by a train? (Probably not that last one.)
  • A behaviorist could focus on the husband’s actions and develop strategies to reinforce or punish the ones she likes/dislikes. This would be pretty manipulative if the husband isn’t on-board, however, so instead the therapist might focus on ways to associate her husband’s hobby with positive emotions and experiences of her own.
  • An existentialist could help Marge delve into the emotional experiences she’s having, what she feels when she thinks of her husband in the basement or buying new models, and what needs she has that aren’t being met. The goal would be either to dissolve the problem entirely by reframing her expectations, or teaching her new tools to manage her mood and satisfy her emotional needs.
  • A systemic therapist could help by examining the overlapping systems she’s a part of; her marriage, her family, her social circles. Did she and her husband used to do more things together? What was their marriage like when the kids were still part of the household? How often does she spend time with her own friends or hobbies? Perhaps there are ways she could better communicate to her husband what her needs are so he can understand how she’s hurting, or examine what behaviors of hers might be reinforcing her husband’s without even realizing it.

While individual modalities might lack scientific backing, I believe the broader philosophies can each be suited to different types of problems. That still means that if a therapist only sees the world through one or two lenses, they might not be able to help their client as well as someone whose approach is the better fit.

Perhaps more importantly, each client can respond better to a different philosophy, even if they present with nearly identical problems. For some, just getting down to brass tacks and tackling the symptoms is their ideal, while for others, digging deep into their psyche is what they want and respond well to.

This is part of the reason why one of the major tenets of good therapy is “stay curious.” The more the therapist starts assuming they know what to expect from a client based on their presenting problem, no matter how often they’ve seen it before, the more likely they are to jump to conclusions about treatment that end up being a poor fit.

III. Modalities

A therapy modality is more specific than a philosophy; it’s not just a framework for what leads to dysfunction and how to correct it, but also a bundle of specific interventions and pathways, some more rigid than others, to lead the therapist and client from first session to last. Here’s just a few examples that I use regularly:

Cognitive Behavior Therapy is a mix of Existential and Behavioral. It focuses on the looping interactions between our thoughts, feelings, and behavior, and how they reinforce each other such that altering one can alter others. (Dialectic Behavioral Therapy leans even more into the Existential side, with extra attention on mindfulness and mood regulation.)

Solution-Focused Therapy is a mix of Systemic and Behavioral. It helps the client identify their strengths and resources in their social systems, as well as how those systems reinforce their behaviors or symptoms, or can be altered to better reinforce more desired ones.

Narrative Therapy is a mix of Systemic and Existential therapy. It asks the client to present the narrative of their life, identify the ways the story they tell themselves and its framing is influenced by the broader systems they’re a part of, then explores the way their narrative makes them feel while teaching techniques to better interface with those feelings.

And here’s a handy-dandy diagram that lists just a few of the different modalities, techniques, and interventions used in therapy. There are many more that exist, and there may be different ways of practicing each of these that bump them from one section of the diagram to an adjacent one, but I believe every modality and strategy of therapy can ultimately be placed somewhere on this image, depending on how much they focus on understanding the client’s past, interfacing with their thoughts and emotions, altering their behaviors, or adjustments to their environment/relationships.

(This is in no way a “complete” image, as there are dozens of different modalities and it would need to be massive to fit them all, but I figured it’s better to just publish with some listed and update it over time.)

IV. Change the Frame, Change the Problem

I like collecting lenses through which to view the world. Each is like a different kind of mental map that I can use to navigate the territory of reality, and just like different types of maps (some simplistic and cartoonish, others realistic and highly detailed) can be more or less useful for different purposes, even maps that I know are not literally correct can still have value.

Overall this post is an ur-map, my ur-map, of different maps I’ve learned about in the field of therapy. I don’t mean to present it as “the one true way to view therapy,” but I’ve found it very helpful, and I hope others can too. It’s also worth keeping in mind that it has many of the biases you’d expect from someone educated in an American college program that focused primarily on one particular philosophy.

Still, I think if more people were aware of the different lenses through which therapy can operate, they would better be able to navigate the sorts of problems that might lead them to a therapy office, maybe even help them find their way without going to one.

Next time you feel stuck in a particular way of thinking about your problems, a particular frame through which your problem seems insurmountable, try changing it. You might find it a lot more tractable than it seemed before.

Therapy

Creating Boundaries


A large part of therapy for many people is learning how to create “healthy boundaries.” Whether adults or children, with friends or family, we often find ourselves having our desires ignored, our time undervalued, and sometimes even our bodies mistreated again and again, despite our attempts to express our preference against such things happening.

People who admit to having poor boundaries often look upon those that do not and wonder what the secret is. How do those people get treated with more respect? Why aren’t they mistreated as often?

There are plenty of potential answers in this space, from demeanor to status to power dynamics, but the most important thing to recognize is that when we talk about social boundaries, they do not exist as barriers that physically stop people from ever violating them.

All “having strong boundaries” means is:

  1. You’ve stated a preference for how you’re treated.
  2. You’ve made it known what your reaction will be if you’re not treated that way.
  3. You follow through on the reaction.

That’s it. Do that enough times, and voilà, you have boundaries.

To make this more concrete, let’s say your mother keeps calling to criticize your life choices or your partner, or a friend keeps invading your personal space, and this makes you feel bad. In fact it may, reasonably, make you not want to talk to your mother or be around your friend anymore.

The first step is to let them know that. Ideally, you’d let them know that you want to maintain a good and positive relationship with them, but that [specific behavior] is keeping that from happening. It’s not a choice on your part, but a consequence of what’s happening, the same way that people do not choose to feel safe or not when someone invades their personal space; they either do or don’t.

Hopefully they will want to maintain a good relationship too. If they protest, try to guilt trip you, etc, just repeat the preference, and explain the consequence; that you’ll hang up/leave the hangout/whatever the next time they do it.

And the next time they do it, do exactly that. And if they protest, remind them that you talked about this, and you’re just following through on what you said.

And keep doing it until either they change their behavior or they decide the relationship isn’t worth them doing that. Which can be sad, but that’s up to you to balance when you set a boundary whether it’s worthwhile or not.

Again, it’s really that simple. Social boundaries are expectations we create from common knowledge, like politeness norms, or our actions. When someone pushes past a line you draw in the sand, or even just stumbles past it accidentally, you have to be willing to push them back, gently or not, or else the “boundary” doesn’t exist.

Ideally, those pushes take the form of calmly stating your desires, and following through on consequences if they’re not respected. Unfortunately, if certain lines are crossed often enough, sometimes enforcing a boundary involves getting really, really mad, shouting and storming out and slamming the door, because anything less than that is just ignored. If the boundary crossed is a physical one, sometimes “pushing back” includes literal pushes.

And part of why some people have a harder time building and maintaining boundaries is that they have been conditioned to not ever do things like that…

…or the people violating their boundaries have power over them. Enforcing your boundaries is always an unpleasant thing to do, and sometimes it can be a dangerous thing to do, especially if your job or physical safety is at stake.

But if you’re never willing to do any of those things, and you feel frustrated that people don’t seem to respect your desires or needs… this may be a large part of why.

Try not to push too hard at first, and don’t push thoughtlessly, but I’m here to tell you it’s okay to push back. The how and when might be complicated, but the will to protect yourself even if it upsets others others is the necessary first step.

Remember that boundaries exist as a way to preserve positive relationships. They should be shared in that spirit, and seen in that light, lest they be misused to pressure people into uneven relationships, or treated as selfishness by others who don’t know how to negotiate preferences properly.

Edit: I’ve found an article by Tasshin Fogleman that goes into more depth about all this, and is worth the read.

Therapy

Trauma


There’s a danger mode that society has been engaging in for years (decades/centuries/millenia?) that simply denied trauma. It was ignorant of trauma, or acted as if it didn’t exist, or verbally repudiated it. People were expected to tough out bad things that happened to them. Men especially were not allowed to express it, except (eventually) if it occurred as the result of war.

The pendulum has swung somewhat, and I hear rumblings of worry about whether we’re treating trauma too seriously. If we’re over-correcting and making things out to be more traumatic than they “really are,” and to what degree trauma is the result of people being told that something that happens to them is “traumatic” or is made a big deal of. This second failure mode concerning trauma is the worry that someone will fall off their bike, scrape their knee, and be taken to the hospital amidst parental tears and shock, thus cementing a lifelong fear of bikes or intolerance of pain.

While I think this second failure mode is probably true for things like how offended or outraged people get by things, I don’t think it’s in our sight-lines just yet for “actual trauma.” Over protective parents are a thing, always have been. If a kid falls off their bike, they are much more likely to cry if their parent freaks out. And yes, to some degree how society treats a thing will inform how people react to it. There are some people who are sexually molested or emotionally abused and essentially move on from it without ever telling anyone, or seeking professional help. This is particularly something you’ll hear from people who are older, and grew up before modern perspectives on trauma or awareness of abuse or rape was as prevalent as it is. There’s a fairly famous older man who got in some hot water for saying something like “Well, I was raped a number of times at the male boarding school I went to, and it sucked, but that was just a thing that happened. The older boys would do that often to the younger ones. It wasn’t the end of the world.”

People will look at accounts like this and be somewhat reinforced in believing that the response to traumatic events is moderately, or even largely, to blame for how traumatic it is.

But the thing to remember about trauma is that by its nature it is anti-correlated to reports and disclosures. You will hear more from the people who recovered from traumatic events or were not traumatized by bad events more often than you will those who were. This is axiomatic to what it even means to be traumatized by something vs not.

On top of the other points, like how no two situations are alike, and no two people are alike, and so making a general rule out of anecdotes is dangerous, it’s also hard to think of people who are actually traumatized by the response to a thing versus the thing itself. My experience is that Eddie Kaspbraks are really, really rare in real life, even in less stereotypical, absolute incarnations.

What I do run across instead, and quite often, are stereotypical incarnations of people who have spent years, if not decades, bottling up their trauma and appearing to all observers, even close observers, as if they’re okay, or as if the behaviors that they have that are harmful to themselves or others are just the result of who they are, and not what they’ve gone through, until something comes out and sheds light on dark machinery. Part of that just comes with the territory of my field of work, but even outside of it, that seems to be far more common than the inverse situation.

And when people who go through events others might call traumatizing, but who were not traumatized by it by some combination of factors that are so far unknown, see such people, I worry that their conclusion will be that this is proof that trauma is the result of low willpower or resilience or “grit” or whatever.

The pendulum may well be swinging toward society being too sensitive to traumatic fears and causing more harm than it’s preventing in highlighting bad experiences as “traumatic.” But so far I don’t know that I’ve seen enough evidence to conclude that for sure, and I hope we get better metrics and tools to determine if that’s in fact what’s happening before we start encouraging a narrative that might make those who suffer from trauma feel in some way as if it’s “all in their head,” like society used to.

Therapy

Arguing with Adults


This is a quick summary and mash-up of the sorts of things I often tell kids about arguing with adults, particularly their parents and sometimes their teachers. 

(0)

Quick disclaimer, a lot of what I’m talking about here is using generalized assumptions, like that your parents are mostly responsible adults, and love you, and have some sense of fairness, and are not suffering from mental illness, and are not in some altered state of mind due to drugs or alcohol. This may not be the case for all of you all the time, and I’m sorry about that. For those of you it does apply to, try not to lose sight of how lucky that makes you. It doesn’t always seem like much, but it at least might allow some of this advice to come in handy.

(1)

Before talking about how to win arguments, it’s vital to understand power imbalances and learning to lose. When you learn self-defense, one of the first things they teach is learning when not to fight at all. If you take a martial arts course so you can go around beating people up, you’re going to get in trouble one way or another. Similarly, you have to be capable of recognizing arguments that are winnable and those that are not, so you can pick your battles. 

Your parents have power in your house, and you don’t. Your teachers have power at school, and you don’t. That means sometimes you have to be ready to lose an argument, even if it means admitting to and apologizing for something that wasn’t entirely your fault, or being the bigger person and apologizing first even when it’s not fair. When you’re older and driving, and a cop pulls you over and tells you you were speeding when you know you didn’t speed, would you argue with them? What do you think would happen next? Arguing with adults as a child can be similar. This does not mean you should not have any pride, or just always admit to things you didn’t do to avoid arguments. It just means that sometimes the real time to fight is later.

If you forget that you’re arguing with someone who has more power than you, you’re more likely to say or do things that will get you in trouble. On the other hand, if you learn to pick your battles, you can earn trust by admitting defeat on things, which will be important in arguments that you can potentially win. Kids who always drag every argument out no matter how many times their parent says “no” quickly lose the impact of fighting hard for something when it really matters and might make a difference. 

(2)

An extension of that is situational awareness, particularly of status imbalances. Parents and teachers don’t just have more power than you, they also demonstrate status differences that are socially reinforced between adults and children in general. If you’re not polite or don’t show respect, even if you have a good reason not to, adults will often get more upset with you than they would if another adult did the same thing.

This is especially true if other adults or children are present: if you are rude to your parents around their friends or while out in public, their embarrassment will often make them more angry with you, and they may feel like they have to be more strict or else be seen as “bad parents.” If you contradict or are rude to your teacher around other students, they may feel as though they have to respond with stronger punishment to show that they are in charge and that the other students have to respect them. Do not forget the social context you’re in when arguing with adults. Try and be polite and respectful, even if you are angry, or you will make arguments even harder to win.

(3) 

With those two things in mind, the most important thing to remember when arguing with anyone is different priorities and values. It is almost impossible to win an argument with anyone if you do not understand their perspective, including what they want or care about, and why. When arguing with your parents, you have to recognize that they have different concerns and goals than you do. To use some simple examples and generalize a bit, they want you to be safe, your grades to be high, and your chores to be done, likely in that order. Most parents don’t care how well you do in your video games, or how much you want to spend the weekend with your friends. This is not the same thing as not wanting you to be happy: I didn’t list that above because happiness is hard to measure, while those other things are not. 

The point is that their priorities are often skewed toward what they believe is best for you and the family in general, right or wrong, and yours are more often skewed toward what will make you happy. A more severe example is that, compared to how much your parents want to be able to afford the bills, they may care very little how much happier you will be if you get to eat out, or can have those shoes or clothes you want. To reduce conflict and improve your ability to reach compromises or win an argument, it helps a lot when you can demonstrate that you understand what they want and don’t shy away from it just because it is not what you want. Show that you actually can take their priorities seriously, and it can be a lot easier to build up the trust needed to convince them to give you leeway sometimes.

(4)

You will almost always be entering an argument with reputation. You are going to be judged by what you’ve done or failed to do in the past. More, you will often be judged by what they believe you’ve done or failed to do in the past, regardless of whether you argue that they’re wrong. And even more than that, you may be judged by what your siblings or classmates have done, mistrusted by association. It’s not unheard of to be judged by what complete strangers do that your parents heard about and are now worried you will do.

All of which sucks. But the one thing you have control over is your behavior, and how well you have earned trust on your own. I can’t promise that everyone will always care about this, but I have often seen how much arguing with bad reputation is like fighting on quicksand. Your behavior sets an expectation of you, and that expectation will either be in your favor or against you. Trust is important in arguments. If you make a habit of saying you’ll do something and then forget to do it, you lose the trust needed to negotiate in future arguments.

So when you’re trying to decide whether to do something or ignore something that will upset someone, particularly your parents, you have to weigh not just the short-term gain you get by doing it, but also the long-term difficulty it will cause you in future conversations and arguments when your parents or teachers are unable to trust you as much as you or they might want.

(5)

Building up all that trust is important, because it’s the cornerstone of any negotiation. This is the actual work of winning an argument with adults. It may not seem like negotiation is the right word for all kinds of arguments, and it may not be for every single one, but you might be surprised by how many arguments ultimately can be described as negotiations, or can be reframed as one to help reach a positive conclusion. 

Kids often argue with their parents about what they’re allowed to do, or what they want, and if the parent is resistant, it’s usually because they are being asked to give something up or compromise something they want, even if it’s invisible or not a big deal to the kid. When you ask to stay up late, from their perspective you’re actually asking them to risk your health or ability to get up on time tomorrow morning, or to risk an argument and being late to school, or make them late to work. Even if it’s on a weekend, you’re asking them to let you change your sleep schedule, which may carry over to Monday morning. These are the things you are negotiating for.  These considerations are what parents often think about all the time.

You have to have something else to offer in return, and I’m not talking about something like money. It might be extra chores that you offer to do, but you can instead also offer your well-being in other ways. If you’re doing well in school, you have more leeway to say something like “I really need some extra time to relax after this week.” What I’ve observed is that parents are easier to talk into the things their kids want when the kid has good grades, does their chores, and is well behaved in general. This probably seems obvious, but it’s worth reiterating that these are things your parents want for and from you, and so they are what you have to negotiate with. This also extends to more important arguments about, say, your future career, or your romantic lives, or your religious choices. These are areas where what you want to be happy and what your parents want for you are at odds because of different expectations about the world and different information.

Arguments like these, including those about some scientific fact or political belief, can also be framed as a negotiation of sorts: the thing you’re negotiating for is often respect. Parents want to make sure that you understand and respect their knowledge and experiences and perspective (whether it’s wrong or not), and offering them that respect as best you can, doing your best to make sure you show that you understand where they’re coming from, can often help a lot in such arguments, even if you still end up disagreeing forever. Which is okay too: it’s normal for parents and kids not to agree about everything. Something worth keeping in mind is that narcissistic or entitled parent may very often just end the conversation at “that’s what I want/deserve” or “that’s just the way it is,” and may not respond well to even simple, unthreatening questions.

There are some arguments that you will never win with your parents, but also should never feel the need to lose, either.  In those cases where your mental health is at stake, where your parents are showing signs of being obstinate, entitled, abusive, or narcissistic, your job isn’t to win the arguments, it’s to survive long enough to gain your independence, and then, if you choose,  create boundaries to ensure your emotional wellbeing.