Help me help myself: therapist edition

June 24, 2022 6:05 PM

I've struggled to find a therapist/counselor/psychologist to meet my snowflake needs around anxiety and overall existential angst. Who should I see?

I've struggled with anxiety all my life, but it's become more acute and unmanageable over the past five years thanks to *gestures broadly.* I've worked with a psychiatric nurse practitioner to adjust my meds and seen a therapist which have helped somewhat, but now I get to add a divorce (and a catastrophic Supreme Court ruling) to the list of things causing anxiety. To top it all off, I'm approaching 50 and starting to feel that I have more years behind me than in front of me, and as an atheist, that's creating a lot of panic and existential dread. I think about death, the (lack of) meaning of life, etc etc a lot, and it's harshing my mellow. My undergrad degree in philosophy has come back to haunt me.

I've benefited in the past from CBT and find it far more helpful than regular talk therapy, but I've found that therapists who say they specialize in CBT still ultimately mainly do talk therapy. I work best from having concrete tasks to do and tools to use, or from someone challenging my worldview or thought patterns with concrete alternatives or logical arguments.

At the risk of sounding arrogant, I'm also probably over-educated and I'm also pretty well-read about psychology, so I really need someone *smart* to work with me or my confidence in their abilities wanes.

I've had a hard time finding someone who fits this super-special checklist, but I don't know if it's because I'm such a demanding snowflake or because I'm not searching in the right way.

So, what kind of practitioner or modality should I be looking for? A PhD? An MD? An LMSW? A guru? A philosopher? A dog?

posted by Ms. Toad to Health & Fitness (14 answers total)

Since CBT works well for you, I think what you are looking for is someone who does a more "pure" CBT approach. I would look for someone who has been trained in David Burn's TEAM CBT approach. (TEAM is just an acronym for testing, empathy, agenda setting and methods - it's still just one therapist - one client).Here is their find a therapist page I would look for someone who has more than just the introductory training and when you interview, ask them what their level of involvement and training is. You want someone who buys into the model, which usually means that they are involved in the community and continually trying to improve their skills as opposed to someone who just took some class a few years and is blending it with other more psychoanalytical approaches.

By the way, degree doesn't matter and smarts doesn't matter - experience and style/personaliity do.
posted by metahawk at 6:37 PM on June 24, 2022 [2 favorites]

You want a licensed clinical psychologist, so PhD or PsyD. Master's level therapists (LSW, LMFT, LPC) are great for many people, but generally do not have extensive training in any particular modality unless they take that on outside their coursework/degree requirements. Clinical psychologists get extensive training in CBT and other modalities as part of their coursework/degree requirements. They also simply have more years of training (4-6 years vs 2). Psychiatrists have also had extensive training, but a large portion of it focuses on the biomedical aspect, leaving less time for extensive training in therapy methods.

You may also have better luck with dialectical behavior therapy (DBT), which is similarly concrete, and people generally don't say they do DBT unless they actually do DBT (though there are always exceptions). CBT is "in vogue" so a lot of people say they do it, and probably are adhering to the general principles, but don't necessarily utilize established techniques like thought challenging, fear hierarchies, behavioral activation, etc.

If you haven't already, I would also be very upfront about wanting that kind of traditional, concrete, goal-oriented CBT. A lot of people really don't like their therapy to be so structured, so many therapists default to a more eclectic style that isn't so concrete. They may be capable of providing CBT in the manner you describe, but many clients prefer a large dose of "supportive listening" with just a sprinkling of CBT. Being clear from the beginning that this is what you want may help; if it doesn't, it's a good sign that you need to try a different therapist as they either aren't able to provide that or aren't willing to listen to you on what you need out of therapy.

Also, if you have a university with a clinical psychology program near you, consider going to their community clinic. You would be working with students, most of whom are likely much younger than you, which may not work for you, but the benefit is they are literally getting assessed on their ability to provide the kind of goal-oriented therapy you're describing. Their supervisors will get on them if they aren't working on an active treatment plan and using the techniques they learn about in their classes. As a student I knew that if I just spent the entire session doing "supportive listening" without good reason, my supervisor would critique that in our weekly supervision. So that may be another avenue to explore.
posted by brook horse at 6:38 PM on June 24, 2022 [6 favorites]

The thing about anxiety is that it keeps you entirely in your head. As a fellow anxious person, fellow smart person, and a therapist myself, I've made the most progress with people who didn't try, or need, to intellectualize with me, who focused more on getting me back into my body. I absolutely could have "outsmarted" them, but I can outsmart a lot of people and it just traps me back in my head. It may be helpful to find someone who's not "smarter" than you but instead values a different way of being in the world. Somatic therapists come to mind.
posted by lapis at 6:40 PM on June 24, 2022 [20 favorites]

That is to say: "A dog" may be closer to what you need than you think!
posted by lapis at 6:41 PM on June 24, 2022 [7 favorites]

That said, if you find a Master's level therapist who endorses training in a specific CBT program (as metahawk linked above--CBT-I also comes to mind), then they probably have received extensive training and are likely just as capable as a PsyD or PhD of providing it. It's just that it's less common for them to have that training than for a PsyD or PhD, so the degree works as a filtering method to increase your chances of getting what you're looking for, rather than a guarantee.
posted by brook horse at 6:41 PM on June 24, 2022

> At the risk of sounding arrogant, I'm also probably over-educated and I'm also pretty well-read about psychology, so I really need someone *smart* to work with me or my confidence in their abilities wanes.

It's good that you're aware of this. This resource-filtering sub-process can really subvert the therapeutic process if you're less-aware. I know at least one really good therapist-author who wrote about the tendency for this to end in a shoot-the-messenger routine for those who have a filtering-perspective on attributes like "how smart are they really," "how much to they fit my idea of what a therapist is," etc.

So if you are at all an autodidact, it's a really good idea to continue educating yourself in providing as much self-care as possible and building / maintaining your best set of therapeutic tools during this process. It's important to hold yourself accountable, first of all, and it also may be important to you at some point to show awareness that therapists are right to throw this back in your lap if they feel it will interfere with your ability to actively manage the care you need from your end. I know some who have become therapists as a result of this kind of self-education setup.

Good luck with your search & keep going.
posted by circular at 6:43 PM on June 24, 2022 [2 favorites]

Your point of view is similar to my own, and what was beneficial to me in the past was a systems therapy group focused on the body-emotion connection. This group helped me do an end run around my thinking mind. I'm not even sure what it would be called these days, but the way it worked was that each person expressed and represented themselves to others in the group only by their immediate physical and emotional sensation (e.g. "I have a racing heartbeat and I am full of dread"). We were disallowed from talking about the "why" of these sensations and emotions, we were not to share or explain what "caused" our feelings, disallowed from literally rational-izing them.

The purpose of each session was to 1) improve our ability to connect sensations and emotions in ourselves, to recognize and name them, 2) to express the sensations/emotions aloud, and 3) and to see our relationship patterns by noticing how we used the sensations or emotions as a way to connect with, reject, or otherwise manage others in the group. As a result it also helped me feel more "grounded" -- until then a squidgy term I was suspicious of. I haven't found anything similar to this group since.

Another thing that has helped this 50ish atheist is spending more time in nature. Not doing something outdoors, not bouldering or getting 10,000 steps in or volunteering to clean a trail, not even "appreciating nature" --- but just finding a spot and stopping, just sitting, listening to it, watching the recursive infinite around me, slowing to the scale of the natural world, remembering that I am part of it. It helps me chuckle at this funny notion of "life's meaning", gives an appropriate scale for my life, renews my sense of hope, and usually minimizes my existential dread because it is so soothingly full and complex that the dread gets edged out.
posted by cocoagirl at 7:04 PM on June 24, 2022 [15 favorites]

Disclaimer: what is written below may not be easy to swallow but is written with only the best of intentions and from direct experience.

The root level answer to your problem is to stop thinking "want" and start thinking "need". You've been trying to go about finding help for that which ails you in a consumerist way: looking for someone or something which can meet your self professed "snowflake" wants rather meet your actual needs.

So what does one who seeks what you seek need? Someone or a program who/which can be a solid sounding board or "mirror" which necessitates that one examine oneself in a fearlessly objective way.

As far as who to seek out for help: I would primarily recommend seeking help through joining a Buddhist monastery if possible. If that is not possible, then joining a Tae Kwon Do dojang (and I do advocate for Tae Kwon Do over other martial arts because of it's relative strictness in a healthy way). Whatever it is, find a practice or institution where you cannot custom tailor the experience to your own terms and instead must follow certain guidelines and principles.

Anxiety is ultimately a result of an untrained mind and discipline (whether CBT, meditation, or martial arts) is the remedy. If people are trees, anxiety and other maladies are what cause a tree to grow sideways and discipline is the splint which ensures that the tree grows up.
posted by defmute at 10:08 PM on June 24, 2022 [1 favorite]

I wouldn’t worry about the degree/type of license. If you strike out with the TEAM directory linked above, I’d go to Psychology Today or another therapist directory and filter for therapists who do CBT, screen out anyone who lists CBT along with twenty other modalities or otherwise seems obviously not a good fit, then contact the resulting therapists and ask directly if they offer a strict CBT approach where the focus is on learning and applying skills. It’s fine to say you’re looking for exactly that. I (a CBT-trained, non-strict-CBT therapist) would tell you I don’t do that, but I wouldn’t try to sell you on a different modality than you’ve been happy with. I don’t know of a search term or other shortcut that would get you to a good candidate faster than asking directly.
posted by theotherdurassister at 10:14 PM on June 24, 2022 [1 favorite]

You would almost certainly find Existential Psychotherapy useful.

Tracking down a practitioner can be difficult, but if you find one they’ll likely be as overeducated as you are.

“[E]xistential psychology centers on what [the originator] refers to as the four "givens" of the human condition: isolation, meaninglessness, mortality and freedom, and discusses ways in which the human person can respond to these concerns either in a functional or dysfunctional fashion.”

The fellow who developed it also wrote (among other things) fiction for therapists. It’s an interesting bibliography.
posted by Tell Me No Lies at 11:37 PM on June 24, 2022 [4 favorites]

Intellectualizing is a great way to distance yourself from emotions and avoid learning constructive ways to deal with them. I say this as an over-educated person myself. It's a habit I am trying to correct.

I find that while I like intellectual therapists, it can also become a distraction or trap to avoid doing the real work of why you are there. A good therapist, even a very smart one, will guide you away from getting too 'in your head'. For a prescribing psychiatrist, yes I want the smartest person in the room. For a healing-focused therapist, what matters most is their ability to guide you through the process, and to steer you away from thinking your feelings as a coping mechanism to side-step feeling your feelings.

I also agree CBT is a good way to retrain an anxious brain, and probably a bit more accessible to the western mind than meditation, though I am a strong proponent of both. Let your therapist know upfront you have a tendency to intellectualize, so they can make a point to help you with that.

I also want to add that CBT is a solution to a symptom of deeper trauma. It is helpful but does not address the root causes. For this aspect, once you have made some progress with CBT and you have a bit more mental breathing room, I encourage you to seek out an EMDR practitioner who also does Internal Family Systems therapy (it's a common overlap) and dig out the taproot of your anxiety instead of just pruning the leaves of spiraling thoughts and negative self-talk.
posted by ananci at 12:38 PM on June 25, 2022 [1 favorite]

Response by poster: These are wonderful responses and resources, and I appreciate the guidance toward grounding myself more in my body and emotions. Thank you!
posted by Ms. Toad at 1:09 PM on June 25, 2022 [1 favorite]

My most successful therapist has been a DBT one who helps me get back in my body and focuses on somatic awareness. It's helped me realize that this over analytical and highly intellectual way of living was a defense mechanism against feeling anxious and helpless, and it's really helped me open up to different ways of being that helps me actively disengage from my anxiety and trust myself more. I think a CBT approach would have kept me trapped in overvalidating the intellectual part of my brain, but not helping me grow in all the other ways that are also deeply useful self knowledge!
posted by yueliang at 1:17 PM on June 25, 2022 [3 favorites]

Unwinding Anxiety hits the criteria of someone smart, concrete tasks and tools, and getting out of the brain and into the body.
posted by Former Congressional Representative Lenny Lemming at 4:52 AM on June 26, 2022