Mental models for therapists

Ideas from the consulting room

What clinicians say about change, trauma, relationships and the work itself.

• The therapeutic alliance

  Therapy needs two people who can work together. Whether the alliance causes good outcomes or merely reveals a patient who could form one is an open question.
  • Psychotherapy cannot help if the participants cannot work together. Jonathan Shedler
  • A prescriber cannot outsource containment to the therapy hour: the emotional and relational dynamics are part of prescribing, not an intrusion on it. Awais Aftab

  From 4 people See all 6 claims

• Early templates

  What a child learned about being seen, comforted or let down becomes the template adults run on: in relationships, in expectations, even in addiction.
  • Childhood trauma is the template for every addiction, including the socially rewarded ones. Gabor Mate
  • The expectation that another person can make everything better originates in early childhood experiences of parents as all-powerful. Jonathan Shedler

  From 5 people See all 9 claims

• The pain beneath the symptom

  The behaviour on the surface is often the visible part of something else: anger over grief, resentment over hurt, addiction over pain. Treating only the surface treats an effect.
  • Addiction is neither a choice nor an inherited disease, but a response to pain: the question is not why the addiction, but why the pain. Gabor Mate
  • Underneath the anger of anxious attachment is unresolved grief about not having been responded to. Julie Menanno

  From 4 people See all 6 claims

• Attachment patterns

  How a person learned to seek safety shows up most when the emotional stakes are highest, and what looks like a character flaw is often a learned alarm.
  • Attachment patterns tend to surface most clearly in the situations that carry the greatest emotional risk. Julie Menanno
  • A person cannot both protect themselves emotionally and build intimacy with a partner at the same moment. Terry Real

  From 3 people See all 7 claims

• The pursue-withdraw cycle

  One partner moves toward, the other away, and each move feeds the other. The cycle sustains itself without either person being at fault.
  • A pursue-withdraw dynamic between partners is self-sustaining and does not require either person to be at fault. Terry Real
  • Avoiding conflict does not actually resolve it, so suppressed feelings build up until they surface all at once. Julie Menanno

  From 3 people See all 7 claims

• Regulate, then reflect

  Insight does not land in a body that is on alert. Calm the nervous system first, then ask what the feeling means, and put words to it as you go.
  • Regulation must precede reflection: cognitive insight fails while a nervous system is in defensive dominance. Arielle Schwartz
  • The first step in regulating stress is to identify and put words to your feelings. Esther Perel

  From 2 people See all 7 claims

• Empathy and validation

  Feeling with someone is not the same as telling them their feelings are valid. Empathy can be chosen, and a therapist who only validates stops being a companion.
  • Telling a patient "your feelings are valid" is not therapy: it is the mirror image of "get a grip", and it makes the therapist a judge of feelings instead of a companion in them. Jonathan Shedler
  • Empathy does not have to be a faucet stuck on: as an adult you can choose when and how much to feel what others feel. Arielle Schwartz

  From 4 people See all 5 claims

• What counts as evidence

  A label like evidence-based can describe what was studied rather than what works. Who was compared with what, and how long the treatment ran, decide what a trial can show.
  • "Evidence-based therapy" is a branding term rather than a scientific one, and in practice it is a code word for "not psychodynamic". Jonathan Shedler
  • A therapy is only shown to be more effective if it is compared against another treatment intended to help, not against a control nobody expected to work. Scott D. Miller

  From 4 people See all 9 claims

General models a therapist borrows

Thinking tools from elsewhere, with a line on how they read in this work. The lines are our reading.

• The map is not the territory

  Every model, word or plan is a simplified map of reality; useful when its structure matches, misleading when mistaken for the thing itself.

  Here: A diagnosis or a case formulation is a map, not the person.

  • A map is not the territory it represents, but if it is correct it shares the territory's structure, which is what makes it useful. Alfred Korzybski
  • The territory never gets onto the map: representation always filters it out, so the mental world is only maps of maps. Gregory Bateson

  From 56 people See all 59 claims

• Feedback loops

  Shorten the loop between doing and finding out; whatever a loop rewards is what you become.

  Here: A couple's fight, a symptom and the response to it can sustain each other.

  • Iteration speed is the decisive factor in making a game: a team that rebuilds every day ends up far better than one that rebuilds every week. Tim Sweeney
  • Twenty years of DevOps had one goal, a single feedback loop from writing code to that code in production, and it failed. Charity Majors

  From 63 people See all 79 claims

• Cognitive biases

  Your mind jumps to conclusions and defends them; look for the evidence against you and use checklists.

  Here: Therapists are not exempt: overrating your own results is one of the best-documented.

  • The psychology of misjudgment is terribly important to learn, and terribly smart people make bonkers mistakes by failing to heed it Charlie Munger
  • Forming an impression very quickly leads to spending the time confirming it rather than collecting evidence, so a wrong first impression is unlikely to be corrected. Daniel Kahneman

  From 18 people See all 39 claims

• Learning machine

  Keep learning after school, and learn from other people's mistakes as well as your own.

  Here: Getting better means seeking feedback on your own outcomes.

  • Learning only from one’s own experience, and minimizing what one learns from the good and bad experience of others, is a sure-shot producer of misery and second-rate achievement Charlie Munger
  • Small changes only compound when they are oriented toward a larger outcome; otherwise they evaporate rather than accumulate. James Clear

  From 13 people See all 20 claims

• Circle of competence

  Know the edge of what you really understand, and act inside it.

  Here: Knowing which clients and problems are yours, and when to refer on.

  • Everyone has a circle of competence, and it is very hard to advance Charlie Munger
  • The size of a person's circle of competence matters less than knowing when they are approaching its perimeter. Shane Parrish

  From 9 people See all 16 claims

• Second-order thinking

  Ask "and then what?": follow a decision past its first effect to the ones that come after.

  Here: What follows from the first relief: a diagnosis, a prescription, a reassurance.

  • Second-order thinking is more deliberate than first-order thinking: it considers interactions and time, and asks "And then what?" Shane Parrish
  • Optimising a single metric is a trap, because the second-order consequences of the change only surface much later. Bill Gurley

  From 88 people See all 110 claims

• Incentives

  Look at what people are rewarded for; it explains more behaviour than what they say, your own included.

  Here: What a care system pays for shapes which treatment gets used.

  • One should never think about something else when one should be thinking about the power of incentives Charlie Munger
  • When a system's incentives produce bad behaviour, the blame belongs entirely to whoever created the incentives. Marc Andreessen

  From 86 people See all 109 claims

• Trade-offs

  Every choice gives something up, so name the cost; and check, because some trade-offs everyone assumes are not real.

  Here: Every treatment and every pace of treatment gives something up.

  • There is a permanent trade-off in verification: an expressive language is hard to prove things about, and a language that is easy to prove things about is hard to write in. Hillel Wayne
  • Engineering has no correct answers the way mathematics and science do; it is the best solution available at the time, and everything is a trade-off. NeetCode

  From 61 people See all 70 claims

• Hanlon's razor

  Do not assume malice where carelessness, ignorance or neglect explain what happened; they usually do.

  Here: A partner's coldness is more often fear than malice.

  • Genuine malice exists, but in most interactions stupidity is a far more common explanation than malevolence. Shane Parrish
  • Failures are more often explained by time pressure than by stupidity or malice. Fabien Sanglard

  From 4 people See all 9 claims

Related

• Therapy approaches: schema therapy, EMDR, EFT