I was reminded of this recently with a patient I was treating. This patient had experienced minimal response to medication changes, and I had suspected from the beginning that life circumstances were the primary drivers of her depression. She wanted to focus on medication, but agreed to try making small behavioral changes to improve her life. At each visit, she failed to make any changes and would ask for a different medication.

I felt a little frustrated. Medications are helpful for many people, and at the same time, they aren’t a substitute for a mentally healthy lifestyle. 

I felt stuck with this patient going into our most recent visit. The medication I had prescribed had been predictably ineffective. The tiny behavioral change we had agreed upon didn’t happen. But she felt much, much better. And in discussing the change, she noted that the psychotherapist on our team had broken the stalemate by asking her to do one simple thing: keep a journal of how she felt each day.

This simple measurement made her realize that certain situations contributed to her depression. It made her realize that she had some control over her mood. And it also helped her recognize that overall, things weren’t as bad as she had thought they were. Even though she hadn’t changed a single behavior, she suddenly felt empowered and hopeful. 

Measurement doesn’t always have such profound effects. And measuring the wrong things may be misleading and even harmful. But if you are struggling to make a change in your life, a good first step may be to start measuring the problem. Build that habit first. It may help you learn what you need to change.

Most importantly, you need to have a great connection. The best therapist in the world won’t mesh with everyone, and it can take several trials to finally get this right. Good therapists want you to ask for a trial session to see if they are a good fit. You won’t offend anyone by walking away if you don’t mesh.

When you find a match, the next step is to establish shared goals. “I like my therapist and I’m not sure it’s helping” is a common concern. Don’t be afraid to ask for change. Every therapist wants feedback about what is and isn’t working. The best will often check in about how the therapy is progressing. If they don’t ask if things are working, you can bring it up. You’re not going to hurt anyone’s feelings.

After developing a good connection and shared goals, it’s important to determine if the skills and form of therapy has evidence to treat your problem. This is what people mean when they use confusing acronyms (CBT, DBT, or ACT, etc.), and cryptic terms (psychodynamic, interpersonal, etc.). You’ll often hear phrases like “CBT works for anxiety.” That is true for many, and it’s still probably less important than having a great connection and shared goals with a therapist. There are many ways to solve most problems, and honest experts often disagree. (My bias has always been towards the so-called “evidence-based” therapies. For some problems, I’m almost always going to recommend a three-letter-acronym treatment. But most of the time, the specific form of therapy doesn’t matter as much as my theory-driven mind would suggest it does).

People often start at the wrong end: choosing a type of therapy rather than starting with connection. That can work if there are multiple experts to choose from. But when your access to therapy is constrained (as it almost always is), it’s usually best to find a good fit first.