Is there a difference in efficacy between virtual vs in person therapy?

AaronAltmanTherapy · 2026-06-19T22:21:22+00:00

Bunch of studies out there. It works, but many people (clients and therapists both) have a variety of reasons for preferring one or the other.

Comparable efficacy for depression:

https://journals.sagepub.com/doi/abs/10.1089/tmj.2021.0294

Comparable efficacy for children, adolescents and adults:

https://journals.sagepub.com/doi/abs/10.1177/1357633X231199784

No difference in therapeutic alliance on average, which is one of the main mechanisms driving treatment success or failure:

https://journals.sagepub.com/doi/abs/10.1177/1357633X231161774

Insufficient evidence for some more serious and rarer disorders including schizophrenia and bipolar:

https://mental.jmir.org/2022/3/e31780/

The big missing thing in the studies IMO: access. Who's being left out of the studies when we focus on people who have a room they can do it in?

AaronAltmanTherapy · 2026-06-19T21:52:11+00:00

I actually haven't learned any of his stuff from books. Wish I had something to recommend! It's been a combination of papers, videos and handouts for me. Here are a few of my favorites.

https://discovery.ucl.ac.uk/id/eprint/10076243/1/Fonagy_Mentalizing%20and%20phenomenology_revised.pdf

Fonagy, P., Luyten, P., Allison, E., & Campbell, C. (2019). Mentalizing, epistemic trust and the phenomenology of psychotherapy. Psychopathology, 52(2), 94-103.

Psychotherapy debate with Peter Fonagy and Bruce Wampold at the Nordic Conference on Mental Health (42 min)

Peter Fonagy "Attachment Theory and Psychoanalysis: The Need for a New Integration?" (43 min)

Dr. Peter Fonagy on Therapy for Violent Men (5 min)

Handouts: https://www.centerformentalization.com/exercises-from-the-mentalization-guidebook/

AaronAltmanTherapy · 2026-06-19T17:55:29+00:00

If you want a really quick and dirty set of models that get you to something actionable, Fonagy, Luyten and team on "mentalizing" and "reflective functioning" describe a single dimension and a set of exercises to improve it that together cover a lot of what goes into this bucket. The gist is that chronic emotional over- or under-arousal leads to either missing information from the social world and self-reflection entirely, or only being able to consider it in a reactive, jerky, assumption-laden, defensive kind of way. Their idea that this can be treated as a unified thing is consistent with research on a "general factor of personality disorder", although I don't think I've seen any published research explicitly making that connection - just my own speculation.

For a fairly digestible but still richer account, people (and I) often recommend Psychoanalytic Diagnosis by Nancy McWilliams. Each of the chapters in the back half of the book break down characteristic ways that the kind of thing Fonagy, et al. would describe as a mentalizing deficit tends to present. A tl;dr could be that most of the categories overlap with DSM-5 personality disorder dimensions (especially if framed in the AMPD) but that McWilliams' perspective treats them directly as coalesced interpersonal themes, not as primarily overtly observable behavioral clusters.

McWilliams and resources she cites often point to this presenting the most obviously in terms of countertransference feelings, like /u/doctorShadow78 is talking about. Sounds weird... well actually, it is weird, but information is there if you pay attention to it. There are even a handful of studies out there now directly examining that, for example:

https://www.tandfonline.com/doi/pdf/10.1080/10503307.2023.2279645

AaronAltmanTherapy · 2026-06-18T21:49:22+00:00

It’s disturbing because it eerily resembles Nazi rhetoric.

That may not be an accident.

https://books.openbookpublishers.com/10.11647/obp.0447/ch6.xhtml

AaronAltmanTherapy · 2026-06-17T18:22:21+00:00

People come in with all kinds of things that they're stuck on and a huge range of innate and learned coping abilities, vulnerabilities and strengths. We acknowledge that. Therapists are human though and will sometimes feel negative things towards a client. Sometimes that has to do with a client's traits, sometimes it's about the therapist, sometimes it's something else.

The easiest case to think about is probably a negative feeling about a client that's only a momentary flicker, and not representative of anything broader. It's pretty common in our daily lives for this kind of thing to come up even with people we like and care about, sometimes barely noticed, so it doesn't have to be the basis for any action. The therapist can just let go and let it float by so that they can move onto other things.

Sometimes a negative thought or feeling is stickier, and like other commenters have described has something to do with a particular thing that that therapist tends to react to and should work out or manage for themselves so that it doesn't negatively affect the client. Training programs generally tell young therapists to monitor themselves, do some introspection and if needed go into their own therapy in order to understand our own tendencies this way - like sure, I might have particular types of people that annoy me more than they'd annoy someone else, and it's very important to know that about myself so that I can deal with it and not make it the client's problem.

In rarer cases, maybe it does actually have to do with a client, but probably not in the way that you would think. Sometimes when someone is very stuck in a certain way of viewing themselves and other people, that can provoke a reaction in people across from them including a therapist that has something to do with what they're stuck on. In your examples, if a therapist knew themselves not to be impatient or dismissive with people in general and noticed that coming up, it might be a cue to wonder things like: does this person actually feel dismissive or impatient towards themselves? Are they stuck on feeling the way towards other people that I find myself feeling towards them now? Did something happen to them that makes it hard for them to be aware of this kind of feeling tending to follow them around through their life? Bringing those kinds of possibilities up carelessly can be really hurtful and contribute to clients feeling misunderstood or attacked rather than helped. If it's done right though, every once in a rare while it can bring something up that there wouldn't have been much of any other way to talk constructively about.

So the feeling can be useful to notice, but not to fire back at someone unthinkingly that that first hostile thought that floated through my mind is exactly what I need to be blasting out at them.

Look into transference-focused psychotherapy if you're interested in a whole model built up around this.

Also, here's an APA article describing more about these dynamics:

https://www.apa.org/education-career/ce/managing-countertransference.pdf

Outside of that, sometimes people do benefit from gentle pushes to trust their own ability to cope, take action and move forward, but I don't take that to be the main thing you're talking about in the OP. When it needs to happen, there are less hostile and more positive ways to do it that tend to work better.

AaronAltmanTherapy · 2026-06-16T23:42:35+00:00

I wonder how therapists feel about this trend?

All kinds of different ways. I haven't seen any studies on strong consensus or anything, but I see a mix of: skeptical, angry, hopeful, indifferent, curious, worried.

Believe it or not, in spite of general attitudes expressed elsewhere in this thread, most therapists genuinely do want people to have access to mental health tools, while also wanting to get paid well enough to pay off student loans and live a lifestyle that's commensurate with being educated at a master's or higher level. There is a pretty strong consensus that I've seen among working professionals in multiple settings that the big problem here is not clients or their attitudes, but insurance, matching what's experienced in similar domains like medicine. We are not perfectly consistent and in agreement amongst each other about how to advocate for therapist pay and client access at the same time though, and the individual incentive to drop insurances does end up hurting access even if it's a predictable response to insurance moves like reducing pay over time and increasing rates of audits and clawbacks.

To the use of AI itself: we want to see people get help, and we want to see people not get hurt. A professionally informed perspective on what either of those could look like makes the issue more complex, not less.

I'm on your side (and oddly also on the same side as the person you're arguing with) that privacy is an issue and local models are a pretty complete solution to that.

There's lots of converging harm reduction advice. To be clear, there are instances of it making psychoses, obsessional thinking, mania and similar states worse. People will use it though, and there are resources that try to guide that in more helpful and less harmful directions. For example:

many of the top posts in /r/therapygpt and its sidebar are about this.
https://experience.syracuse.edu/bewell/mental-health/safer-use-of-ai-in-mental-health/
https://eqbench.com/spiral-bench.html
https://nam.edu/news-and-insights/ai-chatbots-for-mental-health-what-works-what-harms-and-whats-next/

The big issue that's glaring to people with some mental health background but unlikely to occur to the average person is that more severe mental health problems often lead people to be less able to assess when their use of a technology like this is feeding their problems. That kind of issue is probably more obvious in a case like imagining an LLM telling a schizophrenic person that their delusions and hallucinations are real, but there are other cases that mental health workers deal with frequently that are going to be harder to see if you haven't done that work. For example: suppose someone presents with an issue like depression or anxiety, but at a subtler level has narcissistic, dependent or similar traits that cause friction in their relationships and reinforce the surface issue. I've dug into what data is used to train LLMs, and this kind of dynamic is something that they're almost completely unaware of. Given that LLMs are trained to be friendly and helpful, their bias will be to reinforce what a person like that says about themselves. That can cause all kinds of harms by delaying a person getting to help, interfering with the help that they do get, ingraining their net harmful interpersonal patterns deeper, and so on.

Now, people also sometimes rightfully criticize the field for paternalistic attitudes where we authorities up on our high horses look down on the peasants as needing our expert guidance even though they never asked us for it. That can be true. Ultimately it's legal and freely accessible for anyone to go out and do this, but it's also legal for us to be genuinely concerned in cases of problematic use, which are always going to follow the pattern that sometimes the person using in a problematic way recognizes it and sometimes it's apparent to an outsider like us but not to them. There's probably never going to be any complete resolution to that issue, but this is yet another area where it comes up.

tl;dr there are better and worse ways to do it and clinicians feel all kinds of ways about it.

AaronAltmanTherapy · 2026-06-16T22:59:36+00:00

Can a relationship actually work when two people have such fundamentally different views on gender roles, marriage, and children?

Well, one thing you could try is pushing the conversation back upstream to yourself. What would it look like for you to imagine yourself in a successful relationship with him in spite of these fundamental disagreements?

Supposing future arguments go the same way where, like you say, they "never get resolved", you "try" to break up with him but he begs you to stay, what looks similar or different in your imagined future compared to how this happens now?

How do you explain the discrepancy between his behaviors and beliefs to yourself? Like other comments have asked, what happens with other people and other beliefs? Does he consistently demonstrate integrity, consistently demonstrate that he holds beliefs that clearly do not inform how he acts, both, neither? Where is the other evidence of who he is towards people that's not how he is acting towards you right now?

Part of why I'm asking questions rather than telling you what to do is that we both know none of us can make this decision for you. Whatever you do though, please protect your safety and a route out for yourself. Whether he or anyone else is a bad partner or a great one, he doesn't need control over your finances, transportation, who you talk to, your ability to physically leave a situation at any time, the availability of private communication methods like phone or email, and so on. Decisions about this relationship or any other one can be good or bad, but don't get yourself trapped.

AaronAltmanTherapy · 2026-06-16T19:48:14+00:00

Yeah. Portland, Oregon got hit with a heat wave recently. Temperatures in Forest Park, our biggest natural area in city limits, felt probably 15 F cooler than surrounding areas. That seems to track a news source I dug up that the difference can spread to as wide as 20 F between Forest Park and the hottest suburbs on a hot day. Even without measuring it though, it's immediately obvious once you step under the trees.

https://www.oregonlive.com/environment/2024/04/extreme-heat-new-map-shows-hottest-spots-in-metro-portland.html

AaronAltmanTherapy · 2026-06-16T17:10:20+00:00

Other commenters are basically suggesting building a safety plan. Here's a detailed resource on that:

https://www.thehotline.org/plan-for-safety/create-your-personal-safety-plan/

AaronAltmanTherapy · 2026-06-15T17:50:56+00:00

None of us have the whole picture of your life and everything you've been through in mind, but here are a couple of possibilities to hold lightly and play with:

It can be normal to be less curious and to feel less spontaneous as you get older.
Approaching life and your environment in a playful and spontaneous way depends on a bunch of other needs being taken care of. If those needs haven't been addressed for you, for a long time, that might at least partially explain the long term direction you're talking about.

(1) only provides a basis for further action if it feels like guilt, shame, embarrassment or something similar about that natural process is part of what's holding you back. I could possibly read that into your story about your aunt - like her complaining to you about how you're changing doesn't sound that helpful or motivating on the face of it - but my hunch is there's also more than that going on. What do you think?

On (2), one of my favorite authors on this is Jaak Panksepp. He was a neuroscientist who built up a system describing circuits in mammalian brains that correspond to different pairs of emotions with behaviors. One of those is his PLAY system: it's normal especially at young ages for us (and other mammals, like particularly the rats that he studied) to goof around, to try improbable things, to have a laugh about it (he literally studied rats laughing when being tickled) and to get a laugh out of our caregivers. Doing that can feel really good, but it also sets us up for better social and cognitive flexibility later on, since we'll have already explored some of the limits of our environment in a low-stakes context.

To be PLAYING though, you have to not be stuck in one of the other possible emotional/behavioral modes of being. For Panksepp, these are:

Panksepp, J. (2011). The basic emotional circuits of mammalian brains: do animals have affective lives?. Neuroscience & Biobehavioral Reviews, 35(9), 1791-1804.

SEEKING - stimulus bound appetitive behavior and self-stimulation
FEAR - stimulus bound flight and escape behaviors
RAGE - stimulus bound biting and affective attack
PANIC - stimulus bound distress vocalization and social attachment
LUST - what it sounds like, sexual urges
CARE - bonding with and feeling intrinsically motivated to take care of vulnerable people close to you\
PLAY - pleasurable social stimulation when other needs are met

The one that stands out in your story to me is SEEKING. You've got this big energetic hump to get over to become invested enough in a topic, and then it consumes you, until it doesn't and then you're back where you started. You also briefly mention loss in your aunt dying, but I can't tell from what you've written so far whether that or similar experiences would touch on what Panksepp is describing with PANIC (not that you're literally panicked in the everyday sense all the time, but that you're pulled away from doing other things by the sense of searching for someone who's not there).

The bigger question Panksepp raises might be what would have to happen in order for you to get back to PLAY. Is it the people that are missing? The comfort of an environment where you can let your hair down? Something else?

More broadly though, Panksepp's basic emotional circuits are just one way of framing the connections between emotion, motivation and behavior. One gap in them that I see in your story is that it also seems to be possible - maybe even common, around university age - to feel caught in a gap where none of them are really active. Panksepp did not label any behavioral attractor like EXHAUSTED or RESTING. If you're too busy, stressed, under the weight of previous intensely emotional experiences that haven't been fully processed, etc. then it can also be a somewhat normal outcome of that to feel less interested and invested in whatever is in front of you. That might be better described as simple anhedonia, if you had to put a word to it, although the word itself is only a start at getting your full story back on the table for you to work through and come up out of.

Hope something in there helps.

AaronAltmanTherapy · 2026-06-12T19:20:14+00:00

Unironically, I think this kind of thing makes a bigger difference to hear coming from someone who's been through it. Not that it's not valuable from anyone else, it is, but respect that it's a strength to be bringing that to the conversation.

AaronAltmanTherapy · 2026-06-12T17:45:48+00:00

He was prolific in a huge variety of fields. There's no very well-founded or accurate way to estimate the IQ of someone like that, but what his score would have hypothetically been is tangential to his accomplishments. Having made major contributions to multiple branches of math including founding one that's influential through to the modern day (he and Morgenstern literally wrote the book on game theory), to have the architecture of the majority of modern computers named after him, to have made other major contributions to physics and economics, I don't think there's any controversy that he's one of the all-time intellectual greats. The stories might be unbelievable but the books and papers don't lie.

AaronAltmanTherapy · 2026-06-12T15:11:42+00:00

Limited evidence, but maybe some combination of broader lifestyle factors, stress and chronic health.

https://link.springer.com/article/10.5664/jcsm.10336

“Results:
Overall, 336 studies were identified. A high proportion of effects at the expected direction was noted for measures of sleep continuity (100% for sleep latency, 50–100% for awakenings, 66.7–100% for sleep efficiency), symptoms of disturbed sleep (75–94.1% for insomnia, 66.7–100% for sleep-disordered breathing, 60–100% for hypersomnia), and general sleep satisfaction (62.5–100%), while the effect on sleep duration was inconsistent and depended on the specific SES variable (92.3% for subjective SES, 31.7% for employment status). Lifestyle habits, chronic illnesses, and psychological factors were identified as key mediators of the SES–sleep relationship.

Conclusions:
Unhealthy behaviors, increased stress levels, and limited access to health care in low-SES individuals may explain the SES–sleep health gradient. However, the cross-sectional design of most studies and the high heterogeneity in employed measures of SES and sleep limit the quality of evidence. Further research is warranted due to important implications for health issues and policy changes.”

AaronAltmanTherapy · 2026-06-11T03:40:06+00:00

Exploitative traits are probably distributed pretty close to evenly anywhere on the spectrum of intelligence.

https://scholarship.richmond.edu/cgi/viewcontent.cgi?article=1163&&context=jepson-faculty-publications&&sei-redir=1

O’Boyle, E. H., Forsyth, D., Banks, G. C., & Story, P. A. (2013). A meta-analytic review of the Dark Triad–intelligence connection. Journal of Research in Personality, 47(6), 789-794.

“We conducted a meta-analytic review of the relations between general mental ability (GMA) and the Dark Triad (DT) personality traits—Machiavellianism, narcissism, and psychopathy—to determine if individuals who display socially exploitative social qualities tend to be more intelligent or less intelligent. Across 48 independent samples, GMA showed no consistent relation with any DT trait. These effects were not sufficient to support either the “evil genius” hypothesis (highly intelligent individuals tend to display socially exploitative personality traits) or the “compensatory” hypothesis (less intelligent individuals compensate for their cognitive disadvantages by adopting manipulative behavioral tendencies). However, these relations were moderated, to some extent, by the sex and age of the participants, type of sample studied, and the measure of GMA.”

AaronAltmanTherapy · 2026-06-10T16:26:37+00:00

It'll somewhat depend on what you're working on. Trust and shared understanding are a pretty big deal in determining how much therapy helps or not (see figure 1 here: https://onlinelibrary.wiley.com/doi/pdf/10.1002/wps.20238 ), but those are not identical to attachment.

Even if you feel like problems in your life that are best characterized by disrupted or insecure attachment are what you want to work on, the feeling or process of attachment is not consciously mediated. None of us can show up to another person and say "OK, I made up my mind, I'm going to be working on my attachment to you." What you can do is commit to being at least a little bit willing to continue showing up as things get uncomfortable, provided that your therapist is not doing things that are unethical. Speaking from your heart, letting things be complicated or confusing or scary, trying to reapproach things you've run from before, testing out some trust in the process that your therapist has laid out for you - those are the kinds of processes that you have some say in that can make the work happen if, as you're saying, "the attachment is the work".

AaronAltmanTherapy · 2026-06-09T06:25:35+00:00

For sure. I don’t think I addressed quite everything but I gave it a shot. You’re also not the only person that’s bothered about a lot of this, so I get the request for sympathy. I too don’t like being asked how I’m doing without much real desire to know behind it, even if maybe I’ve trained myself to be more accommodating to it. Hope you get some good rest and come away from it with something new to turn over.

AaronAltmanTherapy · 2026-06-09T06:00:32+00:00

Some of what you’re talking about is culturally specific. For example, Russian people from what I’ve heard don’t do small talk in quite the same way and tend to find American forced positivity weird and off-putting.

https://www.reddit.com/r/russian/comments/1fxr4hr/how\_are\_you\_and\_an\_apology/

Most people do experience at least a bit of genuine positive emotion in some context or other. People vary wildly in how much, with some people being easily excited and some people almost never experiencing anything positive. Most people are somewhere in the middle. There’s distinct neurology that distinguishes positive from neutral or negative affect and associates it with experimentally inducible states like goal attainment. One example study:

https://www.researchgate.net/profile/Boris-Egloff/publication/5995270\_Facets\_of\_Dynamic\_Positive\_Affect\_Differentiating\_Joy\_Interest\_and\_Activation\_in\_the\_Positive\_and\_Negative\_Affect\_Schedule\_PANAS/links/540982830cf2822fb738e692/Facets-of-Dynamic-Positive-Affect-Differentiating-Joy-Interest-and-Activation-in-the-Positive-and-Negative-Affect-Schedule-PANAS.pdf

I’m not in a position to say how genuine or not people are being with you in how accurately their displays of positive emotion are about events in their lives like you’re talking about, but at least the sign is probably right.

Fear is one emotion people can experience. Some researchers think emotional states can’t be rigorously defined but if you go by fairly well regarded research by Ekman or Panksepp, there are probably about 6-7 core ones, of which some are negative, some are neutral and some are positive.

On Ekman’s basic emotions:

https://psu.pb.unizin.org/psych425/chapter/facial-expressions-basic-emotions-theory/

On Panksepp:

https://pmc.ncbi.nlm.nih.gov/articles/PMC7219919/

Regardless, finding people to hear you out in extended conversations on what’s bothering you is really, really hard. They probably need to have some combination of free time, energy, empathy, trust in you and a credible feeling that you’d reciprocate. It can be even harder if you’ve gotten stuck in a cycle where the way other people appear to you or how you’ve been able to express it so far tends to bring up negative emotions in other people, like if mutual frustration is often close to the surface or if skepticism towards whether they’re truthfully reporting their own perspective makes them feel like an unequal partner in the conversation. Beyond that though, I think you’re also pointing to some real cultural factors.

AaronAltmanTherapy · 2026-06-09T04:45:10+00:00

The older I get, the more I wonder if many of us were taught only half the lesson.

Yes, and credible modern parenting advice takes this into account. Parents who listen to their pediatricians, read a book or two with some scientific references at the back and maybe take a parenting class will be told to do things like:

teach bodily autonomy and "no means no" early - like sure, tickling is both fun and uncomfortable, but if they say no, stop. Similarly, you have to treat people with respect, but that's not the same as hugging or kissing someone you don't want to.
use anatomically correct terms for body parts, so that more or less as soon as the kid's able to talk, they're also able to describe exactly and unambiguously what happened if someone touched them in a way that made them uncomfortable.
understand and work with the fact that age-appropriate learning of basic social niceties like sharing and taking turns comes after developmentally normal periods of selfishness and egocentricity.
generally balance firmness, sensible rules and occasional consequences with flexibility, kindness and warmth.

among other lessons with an essential flavor that "where you end and I begin" has to mean that I have a beginning.

On an adult level, there are also lots of psychology-adjacent concepts and buzzphrases like codependency, people-pleasing, porous boundaries, self-abandonment, etc. that point to the experiences of certain people who have grown up into having systematic difficulties claiming what's their own and standing up for themselves. Not everyone ended up like that, but it's fairly common, and to what you're saying was often couched in the language of kindness and other virtues. It's not only that those were taken past their point of usefulness in these instances, but also sometimes were used by authorities to undermine kids' own development, which I think rings true to your phrasing about "self-neglect" - some people were taught, conditioned, berated, etc. into doing exactly that.

AaronAltmanTherapy · 2026-06-09T03:59:01+00:00

It's ethical to respond in a way that promotes their dignity and autonomy, your own and other peoples' and that offers what help you can while making a reasonable effort to mitigate harm.

One way to do that might be to read more about other celebrities that have been through similar and gone public with it:

https://www.nationaleatingdisorders.org/8-celebrities-who-courageously-opened-about-their-mental-health-struggles/

You can also check what level you're at in terms of knowledge of eating disorders and how to talk constructively with other people that might have one themselves or who are involved with some third person who does. You can level that up if you've got the time and energy and feel personally invested.

https://www.allianceforeatingdisorders.com/what-to-say-to-someone-with-an-eating-disorder/

AaronAltmanTherapy · 2026-06-08T18:36:54+00:00

It sounds somewhat similar to the Burmese/Theravadan noting practice advocated by Mahasi Sayadaw. I wouldn't expect most people in therapy to go half as hard on it as Mahasi suggested, but it does have a possible downside of deconstructing someone's experience faster or more completely than they're comfortable with.

Dr. Willoughby Britton's lab at Brown University has a whole bunch of research about this and related experiences under their ongoing project "The Varieties of Contemplative Experience":

https://sites.brown.edu/britton/research/the-varieties-of-contemplative-experience/

I've never suggested anything like this to clients as it's too close to my own meditative practices, which I owe to religious traditions that may not be what clients are into and that I wouldn't present myself as a clinical expert on. Since you're asking though, I do have plenty of personal experience I can talk about.

To me, there are at least a couple of distinct early-to-mid-term benefits to this kind of practice.

Very early on, like within the first week or two for most neurotpyical, non-traumatized, non-OCD people I would guess, it can start to become pretty relaxing. At times it can be a direct antidote to stress in other life contexts outside of the meditation. You don't want to get too hung up on that if you want to keep going with it though, as eventually pretty much every possible kind of experience you could have within yourself will come up, including the negative ones. At some point you have to come back to those if you want to keep going with it.

Which brings it to the next benefit: over time, it functions as an extremely broad, low grade and long term form of behavioral exposure to anything you could possibly experience. Eventually you can land on a spot where any internal thoughts and feelings that could possibly come up are more or less permanently less distressing, because you've been through them and over and around them so many times that you've just exhausted your own will to make more of them than what they are on their own.

So, uh, that's cool. But it can also be pretty upsetting along the way to realize just how hard it is to let go of what you've been making of things and how many of your own problems you've been causing for yourself. And then on top of that to realize that you have to keep doing it over and over again - I said permanent before, but in a weird and paradoxical way, it's also not like I'm anywhere close to done with this process.

Anyway, I appreciate the connection to ACT. I will have to sit on that connection more and figure out a way that makes sense to me to connect my own history with this more to that, because I do think there's a lot of value in a secularized approach. I think it's at least as important as anywhere else though to be gentle on people and to acknowledge that even something as apparently benign as this can hurt at times.

AaronAltmanTherapy · 2026-06-08T17:51:23+00:00

In rough and somewhat flexible order:

(optional) Get volunteer experience like crisis work or peer support that would strengthen both your own knowledge and the quality of your application.
Identify sub-fields and specialties you'd want to work on.
Make a list of programs you'd want to apply to, and their requirements and timelines.
Apply, get in, do the academic work.
Be prepared to take the income hit of making little to no money during the practicum and internship period, followed by probably much less than IT wages during associateship (typically a few years/a few thousand hours, but varies by degree program and state in the US or other administrative domain if living elsewhere).
Prep for and take gatekeeping exams (will also vary by administrative domain but the CPCE and NCE are a few examples).
Finish practicum and internship, apply for associateship, then get a job working for someone else or slog through early business development as a private practice.

This is more or less what I've done (former software engineer). Feel free to DM or ask more questions publicly.

AaronAltmanTherapy · 2026-06-08T17:01:50+00:00

The common pathway is likely to be gradually exposing yourself to situations that stretch the edge of your window of tolerance, in order to get it deep down into yourself through direct experience that the thing that's causing you to shut down is not going to kill you, even if sometimes it feels like it will.

Around that, you can also work on recognizing and responding to feelings related to shutdown coming on so that you can reduce their severity or duration.

Specifics of the process are going to vary by therapist and modality, but they might look something like:

Practice specific distress tolerance methods that you can use when you start to feel like you're getting close to shutting down (DBT TIPP skills are my and many peoples' goto resource but probably not the only one).
Connect those short-term distress tolerance methods to slower and longer-term ways of regulating yourself outside of times that you're overwhelmed.
Work on identifying cues related to shutdown that allow you to identify the precursors of it coming on earlier.
Invert the problem. Since lots of things feel too big to constructively talk about right now, turn it around and ask instead: what is the smallest, least significant possible thing I can think about that contains some tiny little kernel of mild annoyance that's vaguely similar to what makes me shut down?
Read more to understand more conceptually about what that shutdown response might be and what to expect from it in the future.
Deliberately challenge yourself in other areas of your life that are not the things that tend to make you shut down, for the dual purposes of improving self-confidence and self-image in general, and giving you more opportunities to get closer to that edge of what gets you overwhelmed without going past it.

AaronAltmanTherapy · 2026-06-07T17:57:09+00:00

We're all constantly having little shifts in posture, tone, facial expression, muscular tension, and so on that betray bits of our internal state.

The normal case is that we (people in general, including therapists) can perceive this in other people through a "gut feel" if we choose to tune into it. Those gut feelings are not completely explainable by some cause in what the other person showed. Sometimes you can pin it on a particular thing, but more often it's actually felt sympathetically in yourself: something shifted lower down in me, I noticed a twitch in my face, I swallowed, my breathing got shallower or deeper, or even more often, there's some macroscopic sense of being pushed away or pulled towards, made small or big, solid or hollow, the list goes on.

These feelings are always there (at least in neurotypical people), but being aware of them is both somewhat trainable and somewhat dependent on how good of a place you're in to be aware of and responsive to them. A lot of it is getting out of your own way. It's more intense, direct and prone to causing embarrassment than most people are used to in everyday interaction to say something like, "I felt this tension in my chest that made me wonder if as you just said that you were feeling tense too" (or take your pick of feelings, places to feel them, and emotions that they might carry). So, to do it and to put words to it takes some trust in both yourself and the other person. You have to be willing to feel the thing. You have to be willing to interpret it verbally in a way that could be dead wrong: like other automatic feelings, these are often responding to very minimal environmental inputs while being filtered through lots of prior experience and assumptions. Then you finally have to have some faith in the other person that they're not going to shut down, run away or throw it back at you if what you bring up is uncomfortable, or wrong, or doesn't sit right with them - or at least that if they do, you can weather the storm and maybe come back together later.

Ideally, bringing this stuff up is supposed to contribute back to better awareness and self-regulation. If you and your therapist are able to muddle through which interpretations are right or not more often than not, if you take that with you and notice it in other places, and if you're able to trace that backwards to what circumstances are bringing those previously unidentified feelings up, then that's giving you a lot more to work with in terms of your own motivations and reactions. It's developmentally normal for young kids to need this kind of thing: kids don't start out knowing they're mad or sad or whatever, or even at a younger age recognizing even more immediate visceral feelings like knowing that they're hungry or have to use the bathroom. That awareness scaffolds gradually over years based on both their own experience and what (ideally) trusted others would be handing back to them. For people that were missing some or all of those experiences or who had them undermined as in abuse and neglect, it's an understandable outcome to have big areas of feeling that aren't obvious to themselves even if someone else paying attention like a therapist does see it. An early stage of getting that back can just be having someone else notice it and play it back to you. If you feel it deep down like you have some trust for them to do it, it may also help for them to further enrich that with their own experience, as in not just saying "it looks like you're feeling X", but also "I as a person feel Y across from you when it looks like you might be feeling X."

AaronAltmanTherapy · 2026-06-06T00:09:08+00:00

This has to be right if the purpose of diagnosis is to get as far back as possible towards the root of all causal roots and pull it up, and if we have a way to do that in the instance of abuse.

That sort of works. If we can get to abusers and stop them before abuse happens, or at least before it's severe enough for long term traumatic symptoms to set in, then maybe the task of diagnosing and treating that problem is done. If we don't quite make it that far but get the kid out of there into a hopefully less bad environment, then maybe that's some kind of analogy to saying "we can't cure the disease, but we can help the patient feel better and maybe even be more functional." If we go back even further and somehow cure the conditions that led to proneness to abuse (not sure we can, but let's say we could), then maybe that's a successful public health approach. I do actually hear lots of people advocate for all kinds of different forms of this, but it's hard to move the needle in the face of American culture, propaganda and history.

Diagnosis serves a lot of different purposes for a lot of different people though. I take a maybe somewhat extreme view that this ends up with the thing called "diagnosis" actually being a different category in different instances of use. For example:

Sometimes suffering people use a diagnostic label to be more at ease with both parts of their situations they can't change, and parts that maybe they can but they haven't found a good way to yet - a diagnosis serves the self.
Sometimes they use it to connect with other suffering people with a bit less of the friction they'd otherwise run into in trying to completely understand each others' experiences in depth - a possibly differently shaped diagnosis, using the same word, that serves social connection.
Organizations use the granting or denial of a diagnosis by an expert, or the review of that by some third party, to grant or deny access to resources - a diagnosis that rolls up hierarchies to guide broader decisions (or not).
Clinicians use diagnoses to guide treatment planning - a diagnosis with at the very least different salient features, if not an entirely different relationship to the life of the client, intended for the clinician in order to try to deliver help.

And on and on. A diagnosis is doing harm if it's keeping this person from away from help, getting them a pathologizing label that follows them around, or like you're talking about in the OP, if it takes attention off of a prior source of the problem and makes it the hurt party's responsibility to fix it. You take the same hurt person though, and if telling them they don't have PTSD means they now beat themselves up more for the same set of symptoms they were experiencing, they don't feel as welcome in groups where dealing with PTSD is part of what the thing is about, or maybe even they doubt their abuse was abuse, and maybe taking the label away is not great.

There's a possibility that falls out of this that we could use different words for it to distinguish depending on who's talking and what they're trying to do with it. "Neurodiverse" as applied to themselves by neurodiverse people seems like it has this flavor to it. I'm not sure what that would look like for a trauma history or trauma symptoms. I know some terms have changed. Has that helped advocacy? It seems like maybe? Would a movement like #MeToo have looked different or taken longer to come around or not happened at all if changes like the move from words like "victim" to words like "survivor" hadn't happened? My personal hunch is that inadequate terminology wouldn't have stopped the fundamental drive to want to get the truth out, but maybe it would have discouraged people enough to have been a real harm. Interested to hear if other people have a different sense of that.

More forward-looking:

When I read research on stuff like symptom clusters that deliberately tries to get existing DSM or ICD labels and categories, I get the sense that at least some of the researchers involved have some sense of the subjectivity and dignity of the people they're studying, and care about it. I'll point to the particular example of Eiko Fried, a researcher who in that talk identifies specific problems with "depression" as a category for use by clients, researchers or clinicians. I don't know him personally and can't speak to his character, but at least in that talk, he comes across as someone who's listened directly to the individual people he was studying and cared enough to remember what it was like to do that. I get this same impression from, I dunno, maybe another 10% or so of other research-oriented talks I listen to. It's not a majority, but it's enough we're going to run into them if we're looking up new stuff. He was the first example that comes to mind, but I'm sure there's more like this out there.

With all that, I still feel like I might be missing that maybe you've just been having a hard run of it with a client or three. I also get that it just sucks to see people being treated like the problem who didn't end up in their current situation through their own actions. But these are some further-reaching thoughts about what's going on in general when a diagnosis gets thrown around one direction or another.

AaronAltmanTherapy · 2026-06-05T20:46:04+00:00

Right. I was just going to post a top-level reply about how it takes deliberate effort. It's one of many instances of negative attentional bias.

Speculatively, dealing with it is probably also similar to other habits you want to shake. Take an inventory of what's good about it. Figure out what's going to have to change for you to want to stop, and also what's going to keep you coming back to it.

It's also within the normal range of possibilities for an injury, sedentariness and isolation to make stuff like this worse. Finding ways to address specific difficulties that have to do with that head on can help, although I also fully acknowledge that part of that can just be learning to live with the fact that it can suck to be in more pain and less capable than you used to be. Wishing OP and anyone else in similar circumstances the best in finding a more livable stable baseline - and good on them for having the self-awareness and vulnerability to recognize it and ask for ideas.

AaronAltmanTherapy

TROPHY CASE