Everyone is telling one another to “get help,” but few acknowledge that the practice is often flawed.
ELEANOR CUMMINS SEP 26, 2022 8:00 AM
AN HOUR A week in a shrink’s office is increasingly treated as a prerequisite for a healthy, happy life. There, we imagine, friends learn new coping skills and enemies realize the errors of their ways. Everyone is “healed.” Therapy has been marketed as a panacea for all kinds of issues, from fixing a bad personality to ending racism. Refusing to seek treatment becomes a red flag, while fluency in “therapy-speak” is all but mandatory. Professional help has even infiltrated our leisure hours: Reality TV shows like Couples Therapy, podcasts from This Is Dating to Where Should We Begin?, and “therapy in a box” card games, some actually designed by psychoanalysts, abound.
Unfortunately, as anyone who’s actually tried it can tell you, therapy often sucks.
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.
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.
The result is that everyone is telling everyone else to go to therapy, but “nobody really creates space to have dialog about, ‘OK, if it doesn’t work, let’s talk about why,’” says psychotherapist Ben Fineman, cohost of the Very Bad Therapy podcast with Carrie Wiita. That’s partly out of fear of uncertainty, which therapists dislike as much as anyone, and partly because reforming mental health care is complicated. But ignoring these shortcomings is only perpetuating the suffering therapy promises to heal.
THE OBSTACLES TO good therapy start when clients form expectations of what therapy will entail—which usually happens well before the first session. People often come in with their own “secret agendas,” says Jeffrey Kottler, author of On Being a Therapist. “They’re being blackmailed, or they want leverage, or they’re seeking reassurance.” Even for those that have reasonable expectations and feel eager to put in the work, the process by which transformation unfolds is murky, and therapists aren’t always the best at explaining what is to come.
All psychic healers strive to “clarify symptoms and problems, inspire hope, facilitate experiences of success or mastery, and stir the patient’s emotions,” as Jerome Frank wrote in his 1961 classic Persuasion and Healing. But the fault lines between professional and public conceptions of therapy are numerous. For example, research suggests that about half of therapy-goers will experience improvement in 15 to 20 sessions. But one study found that the majority of people incorrectly assume they need just six sessions to resolve their issue. Similar gaps in understanding emerge in views on self-disclosure by therapists, the value of negative feedback to therapists, and the purpose of therapy itself.
And while therapy is commonly discussed as if it were a single entity, there are hundreds of distinct theoretical models currently used, from EMDR to Gestalt to CBT. Depending on whom you ask, at least 20 orientations fly under the banner of psychoanalysis alone. Each provides its own model of the brain or mind, the nature of distress, and the path to healing—in other words, its own value system.
Even so, therapists commonly mix and match a number of techniques learned in graduate school, from early mentors, and at weekend workshops. This is done mostly for pragmatic reasons, as every client needs a slightly different form of support. The practice has also been supported by the “Dodo bird verdict” of psychotherapeutic models—named for the Lewis Carroll line, “Everybody has won, and all must have prizes”—which claims that all models are equally helpful or unhelpful.
But it’s unclear if the verdict holds up, says Alex Williams, program director of psychology at the University of Kansas. In fact, very little about contemporary psychotherapy is actually backed by credible evidence. In a meta-review of 70 purported empirically supported treatments, Williams and his colleagues found only 20 percent of the interventions are based on reliable studies. An additional 30 percent were in the “murky middle,” and fully half of the treatments under review didn’t have the evidence their boosters thought they did. For Williams, contemporary therapy is resting on more of a “don’t-know bird verdict.”
Some therapies do appear to be better than others for specific conditions, like exposure therapy for phobias. Others, from conversion therapy to attachment therapy, appear to be dangerous in any context. But even when the underlying method is credible, “most therapists don’t follow a manualized treatment protocol,” says psychotherapist Kirk Honda, host of the podcast and YouTube channel Psychology in Seattle. That makes the line from a controlled trial (where evidence is developed) to the therapist’s couch (where evidence is acted upon) squiggly at best.
To save themselves from analysis paralysis, many therapists fall back on the “common factors,” which suggest that good therapy can be distilled down to empathy, a clear shared goal, positive regard and affirmation, and the like. To date, the so-called “therapeutic alliance” between patient and provider appears to be one of the most important components of successful therapy. Therapy is indeed a “relational art,” and the success (or failure) happens in the unreplicable dynamic between two people. Unfortunately, that insight hasn’t made these alliances any easier to foster.
IN THE US, finding a therapist—any therapist—can feel as difficult as the problem that drove you to therapy in the first place. Many communities have only one or a handful of mental health professionals to choose from, and some American counties have no psychiatrist (who can prescribe medication) at all. What’s more, private-practice therapists rarely if ever accept insurance, so many clients pay out of pocket—a luxury few can afford.
Even for people who have the time and money to choose, it’s hard to know what to look for. In the absence of a referral or personal recommendation, many people turn to “Find a Therapist” databases from their insurance, ZocDoc, or Psychology Today. But current systems are, understandably, designed to prioritize things like cost, proximity, and availability of services—not expertise in a particular problem or a good fit between patient and provider.
Consider a person who is seeking help for time-consuming rituals. They are likely to end up talking to the next-available therapist about more obvious issues, like the depression or anxiety their rituals cause. Even if this person has a hunch that a label like OCD might apply, and searches for the condition by “issue” for OCD on the Psychology Today site, they will receive dozens of results for therapists who have tagged OCD on their provider pages but don’t actually employ the gold-standard treatment, exposure response prevention. To find a provider with expertise in ERP, the client would have to know what condition they have and what intervention they require, then deliberately search for providers by “type” of therapy offered instead. Even then, they may find that the therapist they’re paired with has all the right training but is untrustworthy, unprofessional, or unlikable.
When time is segmented into 50-minute billable increments, clients can’t afford to waste a second. But building an alliance with a therapist—or failing to do so—is often slow going. Some individuals seem supremely skilled at this work: In a 2003 study, psychologist John Okiishi found that, in a sample of 91 therapists, the top performers enabled their clients to improve 10 times faster than everyone else. But even a supershrink would, inevitably, struggle to help certain people.
When a client isn’t making progress, the therapist should be the one to point out the problems and offer a back-up plan. In situations where the alliance cannot be repaired (or never formed in the first place), a therapist will typically refer their client out to a colleague who might be a better fit. But in the US, financial incentives can get in the way. Kottler says therapists may be loath to let a source of revenue walk out the door; after all, their malpractice insurance, rent, and other payments are due. “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.”
Often, that leaves clients in the position of calling the whole thing off. Some end up ghosting. Others tell their therapist that they’re doing better even when they aren’t. Rare is the client who’s able to speak the truth: “You just aren’t helping me.”
ELIMINATING BAD THERAPY entirely, whether in person or online, is a quixotic goal. But improvement starts with freeing both clients and therapists from getting trapped in the current “first come, first serve” model.
Even in the absence of universal health care, government support for mental health could help people access therapy at no cost to them. Without the burden of out-of-pocket fees, patients would be able to experiment. If a therapeutic alliance doesn’t form on the first try, they’re able to find another. “I joke with patients, it’s kind of like speed-dating,” says Jessi Gold, an assistant professor in the Department of Psychiatry at Washington University in St. Louis. Put another way: “We’re the medicine,” Gold says. And what do you do if your medicine isn’t working? You try a new one.
Instead of leaving people to navigate mental health care themselves, Honda thinks government funding could also be used to create a system for pairing clients and therapists—perhaps a combination of algorithmic sorting and trained professionals who serve as a resource to both parties. That way, everyone would have a first, second, and third option for therapy already lined up, with a point person to turn to should problems arise.
Funding could also make a difference further upstream, by subsidizing psychotherapeutic education. Aspiring therapists of color, LGBTQ therapists, therapists from low-income backgrounds, and others with marginalized identities in particular should be supported as they enter a field that is predominantly white and relatively wealthy. When coupled with proactive efforts to decolonize psychotherapy, intentional investment in diversity could help to satisfy clients’ growing desire for cultural competence in all its forms.
Regulation may also be in order. Right now, American therapists are primarily accountable to their state licensing board, but these organizations tend to respond only to ethical violations in the strictest sense. At the same time, there is no federal agency responsible for regulating specific treatments, even those that consistently do real harm. Funding research, putting evidence-based regulations in place, and curtailing misleading marketing practices could save many clients unnecessary frustration.
In the interim, better technical education for therapists could help them navigate a post-pandemic, late-capitalist, and climate-changed country. Many of the most common “presenting problems” are grief and trauma, yet these topics are not currently a core part of many school’s curriculum, Honda says. At the same time, many therapists are reluctant to adopt new innovations as they try (and often fail) to balance the art and science inherent to their work. For example, a 2018 trial showed that routine outcome surveys for clients led to better outcomes, yet the vast majority of therapists remain skeptical of the value of collecting such data.
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.
Eleanor Cummins is a freelance science journalist writing about death, disaster, and bowling balls. She is an adjunct professor at New York University’s Science, Health, and Environmental Reporting Program.