26 votes

Why therapy is broken

16 comments

  1. [2]
    isopod
    (edited )
    Link
    I think this article points out some very real issues. The current crisis did not materialize out of nothing, though, and the solutions the authors suggest - universal mental health care...
    • Exemplary

    I think this article points out some very real issues. The current crisis did not materialize out of nothing, though, and the solutions the authors suggest - universal mental health care subsidies, algorithmic patient-therapist pairing, incentives to drive more psychotherapeutic education - all require a certain concentration of political will that I don't see materializing. It's a nice thought, in other words.

    I think everyone in the field, patients alike, are well aware there are issues. But where do you start? Take the idea of better patient-therapist pairing, for instance. The goal is to pair patients with the right therapist, but how do you quantify what patients need, identify the core issues, understand how different therapists operate? If the therapeutic relationship is this nebulous art, a complex dance, how are you going to reduce it to something we can put into a database and host on a web server? There's probably some headway we could make into this problem today, but the act of helping another person is in no way trivial. Human growth, healing, fulfillment... we can nibble at the edges of these, but we're not going to capture them. That's philosophy, and we aren't there yet. We could educate patients about treatment methods and maybe encourage primary care providers to more accurately refer patients for mental health services, but I don't know - algorithmic matching feels like pie in the sky thinking.

    Right now, what we've got is this: A person visits a therapist, they talk, the therapist describes a treatment approach, and the patient decides if it's right for them. If not, they bounce around a bit and find someone who fits better. Are you really gonna improve that process by inserting yet another algorithm?

    I don't think the lack of evidence-based methods in therapy is necessarily a weakness. Take the studies cited in the article that grab a random sample of patients and ask them whether some therapy helped. How many of them say "yes" even though deep down they're just hopeful, they like their therapist, or they're being polite? How many say "no" because they're resisting a change they need to make or because they had some blown-up idea of what therapy could do? How easy is it for anyone to reduce their progress as a human being to a response like that? A lot of noise in that signal.

    There are certainly ways we could improve mental health. Funding and education, for sure. But even if we had the political will - which I wish we did - people who are in healthy communities and homes, who have things to look forward to, and who are in a functioning society, free of fear and want, are generally a lot less likely to have severe mental health issues. And if we want to point a finger, maybe allocate some resources, I feel maybe we should consider aiming it at the fact that our world falls far short of that. The mental health profession can certainly be improved - but if we don't address the big picture, to some degree, I think we're just going to get more adept at putting band-aids on wounds.

    26 votes
    1. AspiringAlienist
      Link Parent
      I really like this take. Sometimes it is not that difficult to think about possible solutions. Of course politicians and people in power know of this solution. However, it is much easier to blame...

      I really like this take.

      There are certainly ways we could improve mental health. Funding and education, for sure. But even if we had the political will - which I wish we did - people who are in healthy communities and homes, who have things to look forward to, and who are in a functioning society, free of fear and want, are generally a lot less likely to have severe mental health issues.

      Sometimes it is not that difficult to think about possible solutions. Of course politicians and people in power know of this solution. However, it is much easier to blame health care for not providing a (complete) solution to a (partially) social/societal problem than to actually change systems. Or as you put it, the lack of political will.

      4 votes
  2. first-must-burn
    Link
    First, a word about my experience: I am in therapy and find it extremely helpful for managing my depression. I’ve had successful outcomes with three different therapists over the years (changed...
    • Exemplary

    First, a word about my experience: I am in therapy and find it extremely helpful for managing my depression. I’ve had successful outcomes with three different therapists over the years (changed due to changing life circumstances) and have been with my current therapist for five years.

    Although many of the points they make later in the article are useful (finding the right therapist is hard, therapy is expensive, health care models suck), the beginning of the article especially is weighted with misinformation about how bad the therapy itself is. I’m not saying there are no bad therapists, but the claims in the article are pretty misleading given the linked underlying sources.

    For starters, the claims about negative outcomes are not supported by the sources the Wired authors cite. Details follow at the end, but if you want to bin it as “journalists misinterpret scientific study in a conveniently sensational way” and move on with your life, it’s probably reasonable.

    The authors also lump together anything called a “therapy” when most people who seek therapy for depression or anxiety from an individual therapist are going to have some variety of Cognitive Behavioral Therapy which is an effective treatment. The Wired authors lump this in with attachment therapy which (although controversial) is a treatment for a complex disorder in children, not a therapy anyone reading this Wired article is going to experience. They also throw in conversion therapy which the APA supports banning.

    I think the worst outcome here is that someone dealing with anxiety or depression reads the top of the article, says, “yup, that’s what I thought, therapy is not going to help me” and moves on, leaving them to get worse, and maybe think that there is no hope for improvement. People need to know that licensed therapists can help them with their problems.


    As promised earlier, let's break down some claims from the article against the underlying links:

    but at least 5 percent of clients get worse as a result of treatment.

    The two studies linked 1 2 are based on self-reported data collected by survey from only those who chose to respond. Both surveys have a low response rate. Both are from the UK (even though the article is focused on US mental healthcare), and both have significant limitations. You should read the limitations in the studies yourself if you have any doubt, but here are some high points.

    From the first study:

    [Limitations] include a low response rate to the survey and a reliance on patient recall of information about the type and duration of treatment that they received.

    [I]t is important to note that survey data were collected from people who were in treatment or had recently completed it and we do not know the extent to which these negative experiences subsequently resolved.

    From the second source (which heavily cites the first):

    It is also possible that responses to the survey questions may differ depending on whether the respondent was a completer or non-completer of therapy, however this information was not collected as part of the audit

    As neutral and agree categories were combined in order to calculate dichotomous variables, it is possible that some respondents were included who did not experience lasting adverse effects.

    That’s right, their analysis grouped people who responded “neutral” with the “agree” on the question of whether they had experienced lasting negative effects.

    And of course, the all important:

    The cross-sectional design of the study means that we are not able to conclude that the associations we found are causal.

    The article also makes the claim:

    the American Psychological Association and other organizations seemed to prioritize the quantity of available appointments over the quality of any resulting therapy

    The linked study only reports that (surprise, surprise) therapists were overwhelmed with demand for therapy. Nothing about prioritizing quantity over quality.

    23 votes
  3. [4]
    Grayscail
    (edited )
    Link
    The writer references a true point about therapy being very hit or miss at times, but I feel they are conflating a lack of a solution with a lack of effort. I'd say 50+% of people getting some...

    The writer references a true point about therapy being very hit or miss at times, but I feel they are conflating a lack of a solution with a lack of effort.

    Anywhere from 50 to 75 percent of people who go to therapy report some benefit—but at least 5 percent of clients get worse as a result of treatment. (For people from marginalized groups, harmful outcomes may be even more common.) The remainder report no clear benefit at all. Plenty of would-be clients go once and, feeling alienated, never return. Others keep trying, even as it becomes clear they aren’t really getting what they need, whatever that is.

    I'd say 50+% of people getting some degree of benefit is nothing to balk at.

    But the American mental health care system has hardly acknowledged the existence of bad therapy, let alone taken steps to fix the problem. Instead, in the wake of the Covid-19 pandemic, which sent the demand for therapy soaring, the American Psychological Association and other organizations seemed to prioritize the quantity of available appointments over the quality of any resulting therapy. The rise of app-based mental health care, like BetterHelp and Talkspace, has only made this landscape harder to navigate.

    I think they were prioritizing quantity because there was a huge shortage as lots of people decided to seek mental health care as a result of the pandemic and shutdowns. Took me months of calling to finally get even an appointment with a proper psychologist. It was, and still is, a big supply issue that needs continued effort to address.

    For now, it’s important to know that there probably aren’t many truly terrible therapists—just therapists who are bad for you. So while the world waits for a revolution in mental health care, consider getting your break-up speech ready.

    I feel like I see this a lot in opinion pieces, where they start out with a strong clear message, but then as they get into actually discussing it they have to confront a bunch of complexities and by the end the thesis ends up being "Long story short, it's actually pretty complicated and maybe there's no easy answer."

    33 votes
    1. Akir
      Link Parent
      I feel that first quote you put in there is really bad, because it's very easy for a person to misunderstand what it means without any context - which the article has yet to provide at that point!...

      I feel that first quote you put in there is really bad, because it's very easy for a person to misunderstand what it means without any context - which the article has yet to provide at that point! But for anyone with a basic surface-level understanding of psychology will know that there's a wide range of therapies and a wide range of mental health issues, and any given therapy will not universally work on every mental health issue. That statistic is like saying that only 48 percent of solutions fix problems and 12 percent make them worse; it's so general that it's meaningless. And of course some things might not work, but that doesn't mean that they're bad. That's part of why you have a professional involved to monitor the patient's progress; they are there to intervene if it isn't working and to get them started on some other form of therapy! Even with the most hands-off therapies - drug therapy, for instance - you don't just write the prescription and say goodbye forever.

      14 votes
    2. [2]
      phoenixrises
      Link Parent
      I agree with everything you say here, I just wanted to add a reference for people who might be looking for therapy, I personally used Alma to find my therapist that I really like! For me, I got...

      I agree with everything you say here, I just wanted to add a reference for people who might be looking for therapy, I personally used Alma to find my therapist that I really like!

      For me, I got really lucky with my therapist, it took a while but I also have a very specific subset of people that I considered as therapists (generally Asian-American therapists because I feel like they have a better idea of some common experiences in the Asian diaspora). A supply issue is super noticable though, it took me a long time and a couple of sessions of different therapists until I found what I needed.

      5 votes
      1. TeaMusic
        Link Parent
        I feel like I got really lucky too-- my therapist has helped me a great deal. But I also feel lucky that my therapist (and many of the therapists on my insurance list) have similar demographic and...

        For me, I got really lucky with my therapist, it took a while but I also have a very specific subset of people that I considered as therapists (generally Asian-American therapists because I feel like they have a better idea of some common experiences in the Asian diaspora)

        I feel like I got really lucky too-- my therapist has helped me a great deal. But I also feel lucky that my therapist (and many of the therapists on my insurance list) have similar demographic and cultural traits-- white, female, Jewish, local (NYC-metro), etc. The fact that my therapist grew up with similar cultural and family experiences and value systems as I did (and currently has a value system similar to mine) has gone a long way in helping her help me feel comfortable in my own skin. There have been times where certain cultural assumptions come into play that were a non-issue precisely because we were on the same page-- these are situations where I could see rifts forming were my therapist from a different culture. For example-- I live with my parents (I'm 32), and we get along great, but some Americans see this as a "bad" thing. My family lived with family going back as many generations as we can track, and while my (much older) therapist does not live with her parents, one of the first things I noticed when I initially went to see her was that she was practicing out of the basement of a house her dad owned (and used for his own office). Clearly she comes from a family where parents support children.

        There are people from other backgrounds, though, who believe that you aren't a "real" adult unless you abandon your parents and/or they abandon you (obviously, I disagree). I'm not sure it would work out if my therapist felt that way.

        I'm lucky because my demographic is extremely overrepresented by therapists in my area. I feel for people who have to look hard for a therapist that is on the same page as them.

        6 votes
  4. [2]
    TreeFiddyFiddy
    Link
    One thing the article broaches but never really concretely discusses is the inherent predatory nature of the therapist-client relationship for a large subset of patients. I'm on my own therapy...

    One thing the article broaches but never really concretely discusses is the inherent predatory nature of the therapist-client relationship for a large subset of patients. I'm on my own therapy journey and have been for a few years now. Out of five different therapists I've tried, only one was a good fit for me. We had a pause while my therapist went on maternity leave and the two others I tried during that time were so terrible, one of them was outright dangerous and seriously damaging to my mental heatlh during an accute crisis (I was trying to navigate a breakup that left me devastated and she bizarely told me my ex was going to call me to reconnect that night because it was New Years and he didn't want to be alone...wtf). The problem though is that many patients have problems with self-esteem and standing up for themselves so what happens when they encounter therapists who are a bad fit for themselves but can't bring themselves to "break up" with them?

    IMO it should be standard conduct, just like the one therapist in the article, to explain that not every therapist is a good fit for a particular clinet and that if after a few sessions it's not clicking then the patient is explicity encouraged to end the relationship. Working with vulnerable populations that often have trouble advocating for themselves needs a higher level of built-in protections

    5 votes
    1. UP8
      Link Parent
      My problem with therapy is that my schizotypy has been a factor in my life ever since I was in elementary school and every psych eval I've had showed very clear signs in the first paragraph but...

      My problem with therapy is that my schizotypy has been a factor in my life ever since I was in elementary school and every psych eval I've had showed very clear signs in the first paragraph but nobody ever put the evidence together until I did last year.

      Numerous times I've been diagnosed with "adjustment disorder with X" where "X" might be anxiety or depression or conduct concerns. It was somewhat true because I am very well compensated for my condition and I show up when I'm decompensated, but everybody has missed my traits for my states.

      In the late pandemic I tried Betterhelp which had the strong advantage that I could start seeing somebody immediately but no therapist I saw lasted for very long. My primary care doc had prescribed antidepressants which I took for years and when I discontinued (at his suggestion) I felt a burst of self-actualization but also had my schizotypy flare up and I had some pretty strange things happen.

      I got along really well with the first therapist I saw who was broadly supportive and she gave me some ideas about the creative work I am doing which still influence me. (Note I make these things like

      https://mastodon.social/@UP8/110542853660777197

      that combine the real world with fantasy worlds) She had a hard time making their schedule although it didn't bother me. One of my harebrained schemes imploded and the stress of that got me to try another therapist. That therapist was observant about certain signs of my condition but didn't see the whole picture. I was actually very hard on her and we argued incessantly and she fired me. (She wanted me to confront my "cognitive distortions", I wanted to level up my practice of shapeshifting magic.)

      More trouble and the intervention of a friend helped me stabilize myself, it took me about a year to put all the pieces together and understand what was going on. (Turns out my understanding of my neurodivergence was just about right.) I've thought about seeing a professional to get a diagnosis but it is tough today, my doc gave me ten referrals but none are taking new patients, I've sent emails to people who've written review articles on schizotypy and never gotten referalls that panned out. Self-diagnosing autists drive me nuts and I don't want to be that guy... Though I think a lot of self-diagnosed "autists", ADHD, and anxiety disorder patients are secretly schizotypes... We're like 5% of the population.

      1 vote
  5. AspiringAlienist
    Link
    There is not really much to grasp here; of course it’s an opinion piece, but a helicopter view of what is happening with regard to the problem the author of the article proposes would’ve added...

    There is not really much to grasp here; of course it’s an opinion piece, but a helicopter view of what is happening with regard to the problem the author of the article proposes would’ve added some value. Also, the more I think about it, the less clear their message is. Is it that therapy is bad, thus more therapy is needed? Probably.

    The article makes me think a lot of thoughts, of which few are relevant. For whichever goal people seek therapy, or for whichever goal therapists seek patients, it doesn’t really matter. The key point is that therapy is not a complete solution for your problems, as well as that people aren’t supposed to be(come) perfect. Therapy isn’t fun, nor will it help you. You will help you. And that is the difficult task a therapist has; getting you to that point. Cognitively knowing this, will be only helpful in part, but experiencing this again and again will maybe change something. Most likely, nothing will change. Let’s see if there’s yet another therapy modality that will fix this.

    1 vote
  6. Immortal
    Link
    Damn.

    “There have been times in my life, honestly, when my income stream has gone down, and I really need to keep clients and I'm not getting many new referrals,” Kottler says. “And I won't easily let a client go.”

    Damn.

    5 votes
  7. [4]
    DiggWasCool
    Link
    Maybe they should try kidnapping their therapist and keep them in their basement until the healing starts?!

    Others keep trying, even as it becomes clear they aren’t really getting what they need, whatever that is.

    Maybe they should try kidnapping their therapist and keep them in their basement until the healing starts?!

    4 votes
    1. [2]
      Immortal
      Link Parent
      Lol, The Patient reference?

      Lol, The Patient reference?

      3 votes
      1. DiggWasCool
        Link Parent
        Yeah! Just finished it a couple of weeks ago. Great series!

        Yeah! Just finished it a couple of weeks ago. Great series!

        1 vote
    2. lmnanopy
      Link Parent
      The power of health compels you?

      The power of health compels you?

      4 votes
  8. [2]
    Comment removed by site admin
    Link
    1. Akir
      Link Parent
      Yes, insurance and payment is definitely an important issue. Things appear to be better with my healthcare provider these days, but 10 or so years ago they basically only gave you the option to...

      Yes, insurance and payment is definitely an important issue. Things appear to be better with my healthcare provider these days, but 10 or so years ago they basically only gave you the option to see a psychiatrist who will prescribe drugs as a response to any issue, or to do group therapy, which has very limited use when you are dealing with very personal/private things or are having thoughts that aren't socially acceptable. You might be offered individual talk therapy, but chances are they are only approved to deliver cognitive-behavioral therapy, which is not a panacea.

      5 votes