What good therapy looks like, and how to find a therapist who fits

The Short Version

Good therapy is a working relationship with someone who pays close attention, and the quality of that relationship predicts the result better than the school the therapist belongs to. Psychiatrist Paul Conti says research keeps finding rapport to be the most important factor, and Allan Schore says the strength of the therapeutic relationship is the best indicator of whether therapy will help [1][5]. The time to look for a professional, in Lisa Damour's test, is when what you are doing is not working and you have run out of ideas [3]. To find one, ask people you trust or a doctor who knows the local clinicians, and interview a therapist as you would a candidate for a job [1][3]. Expect the work to be hard at least some of the time, plan on roughly a session a week as the minimum for real change, and say so when it is not helping [1]. Peter Attia's account of his own therapy shows what that looks like from the patient's side: named patterns, weekly homework, and more change than he had believed possible [4].

Table of contents

What They Said

When to bring in a professional

Damour, a clinical psychologist, starts by correcting a common idea of mental health. Psychologists do not ask whether someone feels good. They ask two questions: "Do the feelings fit the circumstance? And are they managed well?" [3]. Sadness after a breakup and anxiety before an exam you have not studied for are signs that a person is working as they should [3]. She worries that "for far too many people, uncomfortable feels like unmanageable," so that ordinary bad days get treated as illness [3].

So distress alone is not the signal. She watches for two things. One is mood that interferes with life, such as sadness that casts a pall over everything or anxiety that becomes paralyzing. The other is what she calls "costly coping": getting relief in ways that carry a price, such as abusing substances, being hard on the people nearby, running yourself down or self-harm [3].

Her test for professional help is simple. It is time when what you are doing is not working and you have run out of ideas at home [3]. And she has a way of putting the suggestion to someone who may secretly fear that something is wrong with them: "listen, for what you are up against, you deserve way more support than you have" [3].

Conti adds the line that should not be crossed alone. Many people can make progress with trauma by writing or by talking to a trusted friend, relative or member of the clergy. But thoughts of suicide, or of not deserving to be alive, are warning signs to get professional help instead of working alone [1]. Damour's advice to anyone worried about another person is to ask directly whether they have had thoughts of harming themselves or ending their life. Asking does not plant the idea, and research shows that "if a teenager is thinking about suicide, they're glad you asked" [3].

Sometimes the signal comes late or sideways. Conti says people usually seek the most intensive help at a crisis point, which may be a hospital admission or simply the thought "I just can't take this anymore" [1]. Attia, a physician known for his work on longevity, says his own therapist told him he had been running three plays since the age of five, "obsession, detachment and rage," and had reached the end of what they could do for him [4]. He also describes a patient who did everything he asked with diet, exercise and sleep and barely improved. He knew her father had died when she was in college and that she had been on an antidepressant for some 25 years, and he referred her to a psychiatrist. Within a year, he says, you could not recognize her [4]. He notes that the change in her medication may have played a part [4].

Where to look

Both clinicians who address the search give the same first answer, which is to use people who already know the field or know you.

Conti says word of mouth matters: "If someone you trust tells you, hey, this is a good person, that says a lot" [1]. Damour, speaking of teenagers, says "pediatricians are actually a really good resource," because they know the child and they know the local clinicians, and are often good at making a match [3]. She admits finding someone is hard, partly because there are not many clinicians who specialize in adolescents [3].

Conti's second point is about attitude. People call their insurer, are assigned a therapist, and assume that is the person they must have. He says no. You should look at that therapist as you would anyone you were interviewing for a job [1]. In his conversation with Lex Fridman he urges people to see themselves as empowered consumers and not to settle for whoever is available [2]. Fridman points out that this is hard to do when you are struggling, and Conti agrees. He is sharply critical of a system that rations care through insurance panels and session limits and makes people fight strong currents to get help [2].

Huberman draws the practical conclusion in their conversation: people should perhaps try a few therapists, for a session or two or three each, to see whether rapport is taking root [1].

What to look for

Rapport, above everything. Conti says that if you listed the ten most important things to find in a therapist, the research would have you write rapport ten times [1]. He describes it as someone paying attention, trust, and a real back-and-forth with a person who is in it with you and wants you to get better [1]. The basics he names to Fridman are eye contact, genuine interest, and whether you feel heard and cared for [2].

Range. Good therapists may see the world mainly through a psychodynamic lens, or through cognitive behavioural therapy or dialectical behaviour therapy. But in experienced hands, he says, "it's all coming through the vehicle of the rapport," and they shift to what the person needs. "I want all the arrows in the quiver," he says, and of therapists who say they only do one thing: "When people are pigeonholed that way, I don't think they help their patients very well" [1].

Someone who will not make it easy. This is his corrective to choosing by comfort. "I don't want someone who's going to make it easy," he says, because a pleasant hour may mean the difficult things are not being discussed [1]. Therapy is sometimes enjoyable. Often it is not: "It's hard work. It can be excruciating, we can cry during it" [1]. If you go in expecting that, he says, you are likely to move on from a poor choice and stay with a good one even when the sessions are unpleasant [1].

Attention to your history. Conti notes that some people have been through several residential treatment stays without anyone ever taking a trauma history [1]. A therapist who asks when a pattern began is doing the work he describes [1].

A collaborator. He believes therapy works best as a collaborative human relationship and not as a hierarchy with the doctor at the top [2]. His example is a very sick young patient he could not reach until a supervisor told him to "let him teach you Spanish." After a few sessions of Spanish lessons the young man brought in his mother, proudly showed what he had taught his doctor, felt more capable, and began taking better care of himself [2].

Attunement. Schore, a psychotherapist and neuroscientist at UCLA, describes the same quality from the inside. A good therapist listens to the words and, more importantly, listens beneath them, tracking shifts in the patient's level of arousal [5]. To do that the therapist has to let go of analysis for a moment: "The term for that is surrender" [5]. The therapist first synchronizes, feeling in their own body what the patient is feeling, which may differ from what the patient reports. Then, without spelling it out, they slow or lift their voice, face and gestures to bring the patient's state down or up with them [5]. He says patients sometimes leave a first session saying they do not know why, but they feel better [5].

His summary of what produces change is that it is not what the therapist says or does to a patient: "It's how to be with the patient" [5]. He adds that the test of a clinician is whether they can form that relationship with very different people, an avoidant patient as well as an anxious or a secure one [5].

What the work is like

Saying it out loud. For Conti the central act is putting words to what has been avoided. People fear that if they start they will fall apart, and he answers, "No one ever starts crying and never stops" [1]. When he finally saw a therapist after his brother's suicide, he had to say that he felt he had let it happen, so that the claim could be looked at for what it was [2]. He describes a man who, simply by saying aloud that his coach had raped him decades before, saw at once that it was not his fault [2]. Therapy rarely requires reliving every moment of a trauma, he says. Acknowledging it and asking what it has done to you is usually the work [1].

Finding the pattern. A patient tells him their last seven relationships were abusive, and he suggests it has really been the same relationship seven times: "It's not seven things. It's one" [1]. Attia's three plays are the same kind of discovery [4].

Building an observer. Conti wants patients to develop what psychodynamic therapists call an observing ego, the ability to step back and look at what is happening inside with curiosity, and to separate how they feel from what is true [1][2]. One patient who loved music was driving long distances with the radio off so she could repeat to herself that she was a loser. Noticing that, and asking when it started, led straight to what therapy needed to address [1].

Homework and structure. Attia's account is the most concrete. He works with three therapists, one each for behaviour, psychotherapy and medication, and sees his psychotherapist every week [4]. For rage, the task was a larger emotional vocabulary. He describes a funnel in which every negative emotion, fear and resentment included, came out as rage, and he now does weekly homework on printed worksheets, asking what he felt when something happened and what the emotion was signalling [4]. For obsession, he treats himself as a recovering addict, with a contract, people who act as sponsors, and structured changes that began with a mandatory half hour of play with his children each day [4]. He calls it grunt work and "definitely harder than anything I've ever done" [4]. Of the result he says, "I would have never believed this much change was possible in this short period of time" [4].

The shape of a session. Schore describes an arc. A person arrives from the outside world in an analytical state. Somewhere around the middle of the session they move into feeling, and the voice changes. As the alliance strengthens, the patient can say, in his words, "I'm now going to start to drop some of my defenses" [5]. He points to what he calls "heightened affective moments," stretches of sometimes only 50 or 60 seconds when two people are synchronized and sharing an emotion, which he says drive change far more than intellectual understanding [5].

Ruptures. Schore's account of healthy development includes misattunement followed by repair: a caregiver misreads the baby, notices, and reconnects, and those cycles teach the child to regulate itself [5]. He says the same circuits are at work in therapy, where early attachment patterns resurface [5].

How often, how long, and how to get the most from it

Conti says less than once a week makes it hard to retain progress, so an hour a week is roughly the minimum for real change [1]. More intensive work has a disproportionate benefit. His practice sometimes does about 30 clinical hours in a single week with five or six clinicians, which he likens to a year of therapy [1].

Length varies. A person might need it over weeks, months or years, he tells Fridman [2]. Attia does four hours a week and does not expect a day when he stops altogether. He compares himself to someone in a twelve-step programme who may attend less often in ten years and will still go: "I don't ever want to go back to where I was" [4]. He admits to some lingering shame about needing that much when his wife does not [4].

On preparing and following up, Conti says "there's no hard answer." Do whatever lets you be fully present, whether that is arriving early to sit quietly or walking in cold. Afterwards some people need a walk, a quiet few minutes or notes so the insights are not lost, and others need to set it aside and return to it later [1]. Attia writes in a journal between sessions and brings particular threads into therapy [4].

Conti's last instruction is ownership. Notice when therapy is not helping, including the part of you that is relieved not to face things, and raise it with the therapist [1].

Medication, and what to do if therapy is out of reach

Conti treats medication as a tool that can help people engage in therapy. Some diagnoses usually warrant it alongside therapy. For many others, he says, drugs increase the ability to tolerate distress, and they should be seen as something that may be used for a period, not as a fix or a substitute for work between people [1]. "In American medicine, we are so much better at starting medicines than we are at taking them away," he says [1]. Attia uses a similar idea. Medication is appropriate only when indicated, and good medication can widen what he calls the "bandwidth of distress tolerance" [4].

For people who cannot get therapy, Conti says the essential thing is the same one therapy provides: "bringing new eyes" to what keeps circling in the mind. Ask why you are thinking this and when it started, and do it in speech or in writing, since both engage a kind of self-monitoring that silent thought does not [1]. He warns against a do-it-yourself intensive, such as a whole day of writing about a trauma, because going too deep too fast can make things worse [1].

Schore's answer points to other people. "The real key to changing a right brain is finding people you can be close with," people with whom you can be open and show your shortcomings, as they do with you [5]. Damour says the most powerful force protecting the mental health of teenagers is strong relationships with caring adults [3].

Where They Agree, and Where They Don't

The relationship is the main ingredient. Conti and Schore say so in nearly the same terms, one citing research on rapport and the other the therapeutic alliance [1][5]. Attia's emphasis on living in a relational way points the same direction [4].

It should be hard at times. Conti says so directly and Attia's experience bears it out [1][4].

Emotion has to be reached. Conti says emotion always trumps logic, and Schore says understanding alone does not produce change [1][2][5].

Human connection outside therapy matters as much. Damour, Schore and Conti all say this, and Lewis Howes adds that regular honest conversation with friends does for many women what most men he asked do not have [1][3][4][5].

They differ on four points.

Does the method matter? Conti says the best therapists are versatile and that a psychodynamic, cognitive or dialectical approach can all work through rapport [1]. Schore is more partisan. He says his relational approach produces more lasting change than therapies such as CBT, that "the major change mechanism in psychotherapy now is not insight," and that understanding someone intellectually does not change them [5]. Attia's own progress came with a good deal of structure, including worksheets, contracts and scheduled behaviour, alongside weekly psychotherapy [4]. And Damour notes that for anxiety, psychologists across schools agree on a behavioural remedy, which is exposure in small steps, because "avoidance feeds anxiety" [3]. The sources do not settle this. What they agree on is that no method works without the relationship.

Words or what lies beneath them? Conti puts great weight on saying the thing aloud [1][2]. Schore puts the weight on what passes under the words, through voice, face and timing [5]. These describe two halves of one event. In Conti's own examples it matters that the listener does not recoil [1].

Should it feel good? Conti warns against the therapist who makes it pleasant [1]. Schore describes patients feeling better after a first session and says attachment "is about safety and trust" [5]. The distinction that reconciles them is between the person and the material: safe with the therapist, and uncomfortable with what is being faced.

Self-regulation or regulation with others? Attia's daily tools are largely solitary, meditation and journaling, and he credits labelling his thoughts with a large improvement in his life [4]. Schore argues there has been too much emphasis on regulating oneself and not enough on doing it with another person [5]. Attia would not disagree about the goal, since the pattern he is trying hardest to reverse is detachment [4].

Why It Works

Words create distance. Speaking or writing engages monitoring that silent rumination does not, and Conti says any outward expression is the enemy of persecutory loops of thought [1][2].

Shame loses force when someone hears it calmly. Trauma brings guilt and shame that keep people from looking at it. When they put it into words and the listener does not recoil, they begin to see themselves as they would see anyone else in the same position [1].

Patterns repeat until they are named. Conti's explanation of repeated abusive relationships is that the emotional brain does not respect the calendar and keeps trying to fix the past in the present [1].

Two nervous systems regulate each other. Schore's account is that a therapist synchronizes with the patient's state and then helps shift it, as a caregiver does with an infant, and that the circuits built in infancy are reused in adult relationships including therapy [5]. He cites studies that image two brains at once and find regions of the right hemisphere synchronizing between therapist and patient during real sessions, and he says the process builds new connections over time [5].

A wider tolerance lets the work happen. Both Conti and Attia describe medication and practice as ways of enlarging the range of distress a person can bear while doing the work [1][4].

On evidence: Conti and Schore both appeal to research on the therapeutic relationship without naming particular studies in these conversations, and Schore adds the brain-imaging work [1][5]. Attia's material is personal experience and one patient's story, and he is careful to say he has not figured this out [4].

Where It Applies, and Where It Doesn't

Not all distress needs therapy. Damour's first point is that painful feelings that fit the situation are healthy [3].

Some conditions need medication as well. Conti names bipolar disorder, obsessive-compulsive disorder and attention deficit hyperactivity disorder as diagnoses that usually or almost always warrant it alongside therapy [1].

Access is unequal. Three therapists and four hours a week, or thirty clinical hours in one week, are beyond most people's reach, and Conti himself describes the obstacles the insurance system puts in the way [1][2][4].

Some of this advice was given about teenagers. Damour's suggestion of the pediatrician and her wording for proposing therapy come from work with adolescents, though she and Mel Robbins say much of it applies to adults [3].

Self-directed work has limits. Conti cautions against going too deep alone, and puts suicidal thoughts outside what should be handled without a professional [1].

Schore's framework is one school's account. His claims about hemispheres and his comparison with CBT are his own position, presented with conviction [5].

If you are having thoughts of suicide or of harming yourself, contact a doctor, a crisis line or emergency services now. For everything else here, a licensed clinician who knows your situation is the person to decide with.

What To Do With It

1. Apply Damour's test. Ask whether your feelings fit your circumstances, whether they are getting in the way of your life, and whether the ways you cope are costing you. If what you are doing is not working and you are out of ideas, look for help [3].

2. Ask people who know. Get names from someone you trust who has had good therapy, or from a doctor who knows you and the local clinicians [1][3].

3. Interview, and try more than one. Treat a first session as you would a job interview, including with a therapist your insurer assigns, and give two or three candidates a session or more each [1].

4. Judge by rapport. After each meeting ask whether the person paid attention, seemed interested, and left you feeling heard [1][2].

5. Check for range and curiosity about your past. Ask how they work and whether they adapt their approach, and notice whether they ask when your difficulties began [1].

6. Do not choose the one who makes it easy. Expect hard sessions, and be wary if every hour is pleasant [1].

7. Go at least weekly. Treat an hour a week as the floor, and consider a more intensive stretch at a crisis point if you can get it [1].

8. Say the thing you least want to say. Put the avoided belief into words so it can be examined [1][2].

9. Work between sessions. Keep brief notes or a journal, do any homework, and bring what comes up back in [1][4].

10. Speak up when it is not helping. Raise it with the therapist, and ask yourself whether part of you is relieved to be avoiding something [1].

11. Build the same thing outside the room. Find one or two people you can be open with, and if therapy is out of reach, start there and with honest writing [1][5].

Sources

1. Dr. Paul Conti on Trauma, Therapy, Medication and Psychedelics · Huberman Lab
2. Paul Conti on Envy, Narcissism, Trauma, and the Nature of Good and Evil · Lex Fridman Podcast
3. Dr. Lisa Damour on How to Help Someone You Love Who Is Struggling · The Mel Robbins Podcast
4. How to Heal Stress, Trauma & Mental Health Issues with Peter Attia · The School of Greatness
5. Dr. Allan Schore: How Relationships Shape Your Brain · Huberman Lab