HOWTO therapy: what psychotherapy is, how to find a therapist, and when to fire your therapist

I read this hilarious post by Amanda Rosenberg called “I Asked My Therapist How to Find a Therapist” and cry-laughed the whole way through it. (TL;DR: ¯\_(ツ)_/¯) Because it’s so true: when you need a therapist the most is when you have the least energy, organization, and resilience, all qualities that are helpful in finding a therapist in the U.S. (Most people muddle through with desperation, panic, and flailing instead.)

Finding a therapist doesn’t have to be this hard. As an American, I was amazed to learn that many countries offer free government-provided mental health care. It’s not a panacea – you still have to jump through hoops and fill out paperwork and get referrals – but it does show that there’s no inherent reason why finding a therapist has to be so. Damned. Hard.

Personally, I love therapy – or rather, I love what therapy has done for me and how much happier I am after doing therapy for many years. I have had to find a number of therapists in my life, and recently I used what I’ve learned to help several people I know find good therapists. I figured I’d share what I learned in this blog post, starting with how to find a therapist since that’s the question I get asked most, and then going on to things like how therapy works and how to pay for therapy. It got kind of long, so here’s a table of contents so that you can skip to the part you’re most interested in.

How do I find a therapist?
What is therapy anyway?
Can I go to therapy if I don’t know what’s wrong?
Can therapy help me?
What if I can’t afford to pay for therapy?
What if I don’t have the free time to go to therapy?
How do I know when I should switch therapists?
How do I know when to stop or reduce frequency of therapy?

How do I find a therapist?

In the case that you are paying privately for a therapist at market rates, here is my recommended algorithm:

  1. Search on Psychology Today for therapists near you.
  2. Optionally, filter your results by therapists who use cognitive behavioral therapy (CBT). (CBT is the most evidence-based method of talk therapy. You don’t have to use it as part of your therapy program, but listing CBT as a method of treatment is a positive sign in a therapist in my experience.)
  3. Add any other constraints that are important to you: gender of the therapist, whether they specialized in LGBT issues, if they are a person of color, etc.
  4. Read the self-descriptions of the therapists until you find three that click with you. Be critical and picky and pay attention to how they present themselves.
  5. Once you have three, schedule a free get-to-know-each-other appointment with each of them, preferably in the same week. Go to all three appointments and tell them what you are worried about happening in therapy as well as the problems that brought you there. Optionally, you can send them the Geek Feminism wiki page for therapists.
  6. After you’ve been to each, talk through your experiences with each therapist with someone you trust and pick one. If none of them seem right, go find three more therapists and repeat.

If you have therapy through government healthcare or healthcare insurance or an Employee Assistance Plan or something similar (see the section on affording therapy), use whatever directory or right to choose providers that you have to get an opportunity to work with three different therapists if at all possible. Therapy is in part about the fit or the match between your style and your therapist’s style; there’s no one size fits all. If you can only work with one therapist at a time, see the section on when to switch therapists to decide when to move on to another therapist.

If you are looking to pay privately for therapy but can’t afford market rates, here are some suggestions for finding therapists to interview:

  • Google search for “cheap therapy [YOUR LOCATION]” or similar phrases
  • Search on Foursquare or Yelp or other review sites for the same
  • Search online for counseling training schools near you (they usually have cheap rates for working with students)
  • Ask anyone you know who often works with disadvantaged folks: social workers, court-appointed advocates, activists, etc.
  • If you have any advocates or healthcare workers caring for you – social workers, legal assistance, nurses, doctors, legal advocates, case workers – ask them for suggestions

A great collection of resources for therapy for people with specific needs (such as a polyamory-friendly therapist) is the MetaFilter wiki page on therapy.

What is therapy anyway?

Therapy/talk therapy/psychotherapy is when a patient talks regularly with a counselor or psychotherapist to figure out new ways to think and act so that they are happier. In particular, many of us have developed beliefs and habits about how to be happy and safe that seem to work in the short run, but that end up making us feel unhappy and unsafe in the long run. The therapist helps you recognize these unhelpful beliefs and habits and change them (or at least stop acting in ways that reinforce them). As my favorite advice blogger, Captain Awkward, puts it: “I think every adult could benefit from a look under the emotional hood at some point in their lives.

Many forms of therapy use your relationship with the therapist as a testing ground for trying out new beliefs and actions. In the U.S., a fairly common frequency for therapy is one hour a week or every two weeks. Therapists who use classical Freudian psychoanalysis (what you see on TV shows or movies most often) like to meet for an hour 3-5 days a week.

The forms of therapy differ, but generally they all work better when you are truthful with your therapist, attend appointments regularly, and do any assigned homework. (Conditions that make any of these tasks hard are harder to treat.) The most important thing is to tell your therapist what you are thinking or feeling about therapy or about them, even if it is things like, “I am afraid of you,” or “I feel sexually attracted to you,” or “I want to say what makes you happy,” or “I hate coming to this appointment” or “I’m embarrassed to be in therapy.” It’s the therapist’s job to not take comments like these personally and to use it to help figure out your beliefs. (If they respond to you saying these things with, e.g., anger, or by seducing you, or making you feel guilty, fire them and find a new therapist immediately.)

Can I go to therapy if I don’t know what’s wrong?

Several people have asked me if it is it helpful to go to therapy if you don’t know what’s wrong, or can’t put your feelings into words. The answer is most decidedly, yes. People often go to therapy because they feel vaguely dissatisfied, or incomplete, anxious, depressed, unhappy, empty, tired, hopeless, unimportant, isolated, angry, sad, ashamed, or any number of feelings. People often feel this way even when their life seems objectively great – great job, great family, great friends, etc. If you have figured out why you have those feelings and can put that into words, that’s wonderful – you have a head-start on working with the therapist to figure out what to do about them. But if you don’t know why you feel the way you do, therapists are good at helping you figuring out why.

Can therapy help me?

Oversimplifying wildly, here are the requirements for therapy to work as I understand them:

  1. Self-motivation: Do you want to change badly enough to do scary hard things?
  2. Self-criticism: Can you accept and internalize criticism?
  3. Self-discipline: Are you willing to put in the effort to change, even if it is hard or scary?

It’s okay if you’re not that good at accepting criticism or at consistently applying yourself, as long as you’re motivated to get better at those two skills for reasons you find compelling. But if you’re going to therapy in order to appease or manipulate someone else, but don’t actually think you need to change, it’s less likely to work. Most of the work of therapy happens outside the time that you meet with your therapist, and you are unlikely to do that work if you don’t see how it benefits yourself. This kind of motivation normally fluctuates – I’ve several times taken a break from therapy because I didn’t care to work on my problems at that particular time. I came back when I was motivated to do the work again, sometimes years later.

Several psychological symptoms or disorders interfere with one or more of self-motivation, self-criticism, or self-discipline. These include (but aren’t limited to) depression, anxiety, difficulty staying focused, narcissistic personality disorder, and antisocial personality disorder (ASPD, better known as psychopathy or sociopathy).

If you have depression, anxiety, or difficulty staying focused, therapy will be harder but still doable with effort and advice from your therapist – after all, these are some of the most common reasons people go to therapy.

Narcissistic personality disorder presents as extreme outward confidence, disregard for the feelings of others, and obsession with personal image. One of the less well-known aspects of narcissism is the inability of the narcissist to accept and internalize criticism. It is difficult to improve at any skill if you can’t directly face and accept feedback on how you are doing it wrong. As a result, someone with narcissism has great difficulty changing anything about themselves for the better. Narcissism is notoriously difficult to treat. (If you’re seriously wondering if you are a narcissist, that is an excellent reason to go to therapy. The answer is probably no, but either way, talking to a therapist is a very good idea at this point.)

People with Antisocial personality disorder (better known as sociopathy or psychopathy) have difficulty caring about or understanding the needs or feelings of others, are impulsive, and have difficulty imagining or caring about negative consequences for their behavior. Many people with ASPD are quite content with their personality and actions and see no reason to change them – although some proportion of people with ASPD decide to be a positive part of society anyway and it’s not clear why they are different. Some proportion of ASPD cases are due to permanent impairment of specific brain structures; they can use therapy to learn different behaviors but won’t ever recover that specific brain function. Other folks have neurotypical brain physiology and acquire ASPD after experiencing intense abuse and trauma. Therapy can sometimes help them recover full function.

Other things that can make it harder to get benefit out of therapy: a mental illness, an addiction, an allergy, not getting enough sleep, and being in an abusive relationship. Often, therapy will have the side effect of helping you to solve or reduce these problems, but fixing them may also take medication, diet changes, social support, and time.

What if I can’t afford to pay for therapy?

I’ll assume if you’re asking this question you don’t have access to state-provided healthcare, such as citizens or residents of Australia, Canada, or many European countries. To start finding therapy in this case, my understanding is that you usually ask your general practitioner or primary care doctor for a referral. The rest of this answer will focus on countries that don’t have this.

The easiest way to get therapy (even in countries that provide it for free through the government) is to have enough disposable income to pay the market price for therapy. If you have the money, go this route. If you don’t have the money, you’ll be amazed at the number of ways to get therapy at below market rate. Here are some of the ways to get therapy at a lower price.

You may have private health insurance that covers therapy. However, relatively few therapists accept the extremely low rates paid by insurance, and those that do often have long waiting lists. If you have more money than emotional energy or time, I recommend not even trying to get therapy paid for by health insurance. Otherwise, go to your health insurance web site and look for information on using your mental health benefits. They will probably have an online directory of providers who take your insurance.

Your employer may have an Employee Assistance Plan that covers therapy, usually a specific number of sessions, like six (which is laughably low but better than nothing). The nice thing about EAPs is that usually there is a hotline that you can call and say, “Help me get a therapist,” and they will do the work. This is extremely helpful!

For the case where you can’t afford full price for therapy, but you could afford, say, 25% – 75% of normal costs, many areas have a school for training counselors with students who need patients to practice on. They usually charge need-based sliding scale fees. Many individual therapists will also charge on a sliding scale basis – just ask when you first speak to them. Many therapists also list their price ranges on their Psychology Today profile. Another option in this price range may be online counseling services like In Your Corner.

If you can’t afford that, many community service organizations provide free counseling as part of their services or can help you find free counseling. Homeless shelters, halfway houses, LGBT youth centers, and addiction centers are some places that will be willing and able to help you find free or very low cost therapy.

[2017-09-17 Update: This Twitter thread from Tiffany Howard is a great source for finding free or low cost therapy.]

What if I don’t have the free time to go to therapy?

If freeing up the time to go to therapy seems impossible, here’s my suggestion: move heaven and earth to go to one appointment and tell the therapist why you don’t have time for regular therapy. Then they will be able to suggest ideas for how to make therapy possible for you, based on their far more extensive experience working with many different patients. Remember, it’s not a matter of having time for therapy, it’s a matter of prioritizing therapy just slightly higher than other things in your life that you spend a couple of hours a week on. If therapy is key to you staying alive and functioning, then it’s worth exploring the options.

Some useful options for some people with little money and an uncertain schedule and certain types of problems are the various twelve step programs that branched off from Alcoholics Anonymous, especially the program for the friends and families of addicts. Twelve step programs are free (funded by small voluntary donations from those who can afford it) and usually have meetings at a variety of times in major metro areas. They also have meetings within prisons and hospitals and even phone-based or online meetings. These programs can also be helpful for people who can afford therapy, and many therapists recommend joining the appropriate twelve step program in addition to therapy. Check out the list of twelve step programs on Wikipedia to get an idea if one of those is a good match for you. Note: there is significant research questioning the effectiveness of twelve step programs compared to naltrexone for ending alcohol and narcotic addictions. I agree that twelve step programs don’t work for everyone and attendance shouldn’t be court-mandated; at the same time, some twelve step programs are helpful for some people and are definitely cheaper than most therapy.

One last plug for trying to make therapy work in the face of obstacles from my favorite advice blogger, Captain Awkward: “I recommend therapy here a lot. And I will keep doing it. Even though it is often prohibitively expensive. And/or difficult to locate. And/or difficult to acquire once you do locate it and can maybe afford it. I have a very strong bias in favor of therapy/counseling/mental health services because I have found them to be personally extremely helpful to me and to people I love – some of whom are alive and breathing because they sought out mental health services in time to save their own lives.”

How do I know when I should switch therapists?

Sometimes you aren’t done with therapy but you need to work with a different therapist. This can happen for a lot of reasons. The easy reasons are things like: you develop a symptom or a condition that the therapist doesn’t feel qualified to treat, you move away and they aren’t willing to do therapy over the phone or Internet, or you can no longer afford to pay this therapist’s rate. The less obvious reasons are when therapy isn’t working for some subtler reason: you’re still showing up to therapy and doing homework, but things aren’t progressing. Are they not working because you aren’t ready or doing the work, or is it because you and the therapist are a bad match for each other, or is it because the therapist is bad at their job?

Here are some red flags for therapist relationships that aren’t working out and should probably be ended:

  • The therapist creeps you out (no need to put it into words or get more specific)
  • The therapist attempts to make you feel guilty
  • The therapist makes any kind of sexual advance (or accepts your sexual advances – they are in the position of power and should never accept your advances if you make them)
  • You find yourself unable to stop lying to the therapist
  • The therapist talks about themselves for more than a few minutes per session
  • The therapist does things that make you feel you need to care for the therapist (e.g., becomes visibly upset and requires soothing from you)
  • The therapist “one-ups” you by sharing information about themselves that inhibits you from speaking about your own comparatively minor problems
  • The therapist is unable to hide their anger in session with you
  • You feel belittled or smaller or beaten down after sessions
  • The therapist relies on information provided by your abusers or an unqualified third party (e.g., a parent defining what is wrong with their child)
  • The therapist dismisses your feelings (this is different from searching for underlying feelings or first feelings that turn into your current feelings, a normal activity)
  • You find yourself “accidentally” missing appointments (though this could be a sign that you need to end therapy entirely too)
  • The therapist says things or takes actions that make you feel like you are broken or weird
  • The therapist tells you that something is concerning or bad, but does not help you address it
  • The therapist doesn’t make an effort to understand things that are important to you, like your job or online community
  • The therapist has difficulty remembering important facts about you between sessions
  • The therapist can’t hide that they don’t share basic values with you, such as feminism
  • You find it very hard to tell them that therapy isn’t working for you in some way
  • The therapist offers advice outside the boundaries of the therapy relationship (e.g., about sports or nutrition)
  • You are comfortable and unchallenged in most of your sessions
  • Your take away from most sessions is that you are a really great person who is doing nothing wrong and doesn’t need to change anything but for some reason you need to keep coming to therapy
  • You feel like you are able to fool or charm or manipulate the therapist into doing what you want

Overall, you should feel like your therapist is supporting you in doing difficult, painful, but necessary work. If seeing your therapist makes you feel worthless or helpless or more self-critical, or if they simply affirm you without helping you grow in ways that are difficult for you, you’re not getting the help you need.

Here are some normal (but not necessary) experiences in a relationship with a therapist that is working:

  • You cry. A lot. In session, out of session, on the way to sessions, at work, at home, everywhere
  • You feel sadness and grief more intensely than you have in years
  • You feel strong guilt and anxiety (but not as a direct result of the therapist’s actions or words)
  • You are simultaneously dreading and looking forward to your next appointment
  • You get angry with your therapist in the session (but they do not express anger towards you)
  • You avoid appointments because you don’t want to talk about a specific subject
  • You have to drag yourself into the appointment
  • You sit silently for most or all of the appointment
  • You want to say something to your therapist but you are afraid to and spend the whole appointment avoiding saying it
  • You want to please the therapist and be the perfect patient
  • You don’t want to make your therapist feel sad by telling them unpleasant things you have experienced
  • You deliberately insult or shock or act rudely towards your therapist
  • You show up late to appointments
  • Your therapist reminds you of someone important in your life (mother, ex-husband, etc.)
  • You feel guilty for taking up the therapist’s time
  • You feel like you should be making faster progress
  • You are really tired after an appointment

You can also be having any of these normal experiences with a therapist who is still a bad match for you, just don’t think that these experiences alone are a bad sign.

How do I know when to stop or reduce frequency of therapy?

Spending time and money on therapy has diminishing returns at some point for many people, and at some point you can have a perfectly fine working relationship with a therapist but not have any motivation to continue therapy. Some signs that it might be time for you to reduce frequency or end therapy are:

  • You start forgetting your appointments because you aren’t thinking about what you’re going to discuss at the next one
  • You made a lot of progress in one area of your life but you aren’t much interested in working on any other area right now
  • You feel like you aren’t connecting with your therapist after several weeks
  • Your appointments are uniformly boring
  • You have difficulty thinking of things to say (as distinct from having things to say but not wanting to say them)
  • You keep cancelling your appointments because other things are more important

It can be uncomfortable bringing up the topic of ending therapy with your therapist. Keep in mind that they have been through this many times and that for them, it’s like having a student graduate (in the best case). Just say, “Hey, I’m starting to wonder how much longer I should be in therapy. What do you think?” If you are worried that you want to end therapy for the wrong reasons, or shouldn’t end therapy, your therapist is a good person to discuss that with.

I hope some of this advice is useful to you! I love therapy and it has made me a much happier and healthier person – after years and years of difficult hard work and buckets of tears, so don’t give up too quickly. I wish you all the best for your journey towards greater happiness!