How therapy helps

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Psychotherapy as a Developmental Process gives three ways therapists help their patients:

  • Attention guidance — pointing out something the patient has not noticed.
  • Enactment — training the patient.
  • Interpretation — giving the patient a framework they can use.

If you want to help people by talking to them, read this.

Attention guidance

I think attention guidance is the best form of therapy in terms of return-on-investment.

You point out something the other person would agree with when stated out loud. Maybe it's something they already think but were afraid to admit. Maybe it's a contradiction between their own beliefs.

This is where it helps to have a lot of life experience of your own — it makes it possible to recognize and point out many different things.

My Twitter — @TheOrangeAlt — works like this. I notice things and I state them clearly so that others can recognize them in their own lives. @QiaochuYuan works like this. The thing about people not knowing they were abused, until you tell them what abuse is — is 100% this.

"I feel X" is attention guidance. "A lot of people feel X" is attention guidance. "You said you feel X two days ago but now you say you don't" is attention guidance.

Note that guesses like "you probably feel X" are not this. They are attempts to force someone to believe the thing, not notice it. "What if you feel X?" can be attention guidance only if you're genuinely unsure they feel X. Otherwise it's a bad form of interpretation. We'll get to it later.

A dense quote from Psychotherapy as a Developmental Process (god this book is hard to read):

When therapists assist clients in maintaining simultaneous attention to the full range of their experiences and ways of representing and making sense and meaning of their experiences, and the contradictions or conflicts among them, we view this as contributing resources to the dialectic of attention.


I think enactment is the highest-impact form of therapy, but it's hard to do well.

Enactment is training the person to handle a situation by letting them practice. An example is being a friend-on-training-wheels for someone, i.e. a friend who gives extra feedback on how to participate in a friendship. (Or just a friend with higher tolerance for occasional fuck-ups.)

Enactment can also be — guiding someone through a dialogue. "Okay, what would you say to that bully if you met them again? Let's say they answer X. What do you reply now?"

The simplest example of enactment is telling someone to count to ten when they feel angry — and, ideally, reminding them to do it the next time they get angry. Training is not simply telling people what to do — it's also making sure they actually get a chance to try it.

Serving as a good example for imitation is also a form of enactment. You train the person to handle life by showing them how you live your own life. To do that, you need to be good at life. This is hard.

Marie Kondo's The Life-Changing Magic of Tidying Up gives an awesome example of enactment — you can fight your messy family all you want and the house will stay messy, but when you work on getting your own place clean, they suddenly get motivated to tidy up as well. It actually works.

Psychotherapy as a Developmental Process:

When therapists assist, guide, direct, or participate in the creation of novel experience, in which clients’ skill structures are activated, accommodate to new situations, and become objects of reflection, we view this as contributing resources to the dialectic of enactment.


Interpretation is — providing insights, or pointing out that some things are often connected, or even channeling a whole new worldview and hoping the other person will adopt it.

For me, it's the least useful form of therapy. I don't adopt others' worldviews easily.

"Think — what if [your bully] is scared of failure?" is interpretation. The other person has no way to check. There's nothing for them to notice. You are hoping they will start thinking about the bully differently, more like you think, perhaps, and change their behavior in the process.

The Last Psychiatrist is very much in the interpretation camp. His worldview comes at you at full speed through his (awesome) rants. If you adopt it, you might start changing. I did actually adopt it, but his writing wasn't useful to me anyway.

"Growth mindset" is interpretation, based on what I know about it. Every catchy saying ever — interpretation too. (If it's actionable, then maybe it's also a bit of enactment.)

Interpretation is what people think about when they say "ugh, don't give me solutions, give me support".

Psychotherapy as a Developmental Process:

When therapists assist by offering conceptual-representational schemes and structures drawn from their own ways of making sense of experience, which then may be deliberately brought to bear on making sense of the client’s experience, we view this as contributing resources to the dialectic of interpretation.


Actual therapy can, and likely should, combine all three forms. The lines are blurry.

Getting Things Done is half-enactment, half-interpretation. It gives you a system, but also tells you the system is the right one. If you believe it, the system will work better.

Giving someone a framework is interpretation, but giving someone a more fleshed out form of a framework they already agree with — that is closer to attention guidance.

Walking someone through an episode of anger, and trying to figure out where that anger comes from — well. If you have a guess that "it's because of their mother", it might take you some interpretation to get them to entertain this possibility. It will also take some attention guidance. But at the same time you are teaching them how to walk through episodes on their own. Teaching is — enactment.

Some things don't fit at all. For instance, what is emotional support? It's a kind of enactment, but only in the same sense as "paying for someone's tuition" is "teaching them". You aren't teaching, you are providing a resource they need to start learning on their own. Emotional support by itself is content-less as a therapy, but it's not useless — it supports the actual therapy or self-therapy that will be done later.