The Trouble With Talk Therapy

“What brand is your therapist?” Exploring the latest marketing trend among psychotherapists.

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In a recent Sunday’s New York Times article, a psychotherapist with a freshly hung shingle describes the challenges of earning clients in a market crowded with professionals willing to listen, but with a dwindling number of patients. Her solution? Turning to a “branding consultant” who advises her, among other things, to sell herself as a specialist treating a particular type of patient and to start doing “life coaching” instead. But the trend toward “branding” may be diverting attention away from deeper problems with psychotherapy that are dissuading people from trying it and discouraging insurers from paying for sessions.

MORE: Phone-Based Psychotherapy Helps Depression, At Least in the Short Term

In the article, therapist Lori Gottlieb writes:

What nobody taught me in grad school was that psychotherapy, a practice that had sustained itself for more than a century, is losing its customers. If this came as a shock to me, the American Psychological Association tried to send out warnings in a 2010 paper titled, “Where Has all the Psychotherapy Gone?”

According to the author, 30 percent fewer patients received psychological interventions in 2008 than they did 11 years earlier; since the 1990s, managed care has increasingly limited visits and reimbursements for talk therapy but not for drug treatment…Three months into private practice, I had exactly four regular weekly clients.

Her branding consultant tells her “Nobody wants to buy therapy anymore. They want to buy a solution to a problem.”

While that sounds to me like a hopeful desire among people seeking help for mental illnesses, to Gottlieb, it’s a shocking development and reeks of seeking “immediate responses and constant gratification.”

MORE: Do We Really Need Psychiatrists To Do Therapy?

She sees therapy in a more “Woody Allen” mode, like the endless sessions of psychoanalysis practiced in the 1950s and 1960s.  She wants to explore “unconscious feelings” about other people transferred to the “blank slate” of the therapist and to provide the “opportunity” for a patient to “truly understand himself and, ultimately, change.”

But psychological research on effective treatment for disorders like depression, anxiety disorders, obsessive-compulsive disorder, post-traumatic stress disorder and the like has moved far beyond this view.  Indeed, the most effective treatments for these conditions do not prioritize digging into the unconscious.  As Yale psychologist Alan Kazdin put it when we discussed a 2011 article he wrote on the problems with individual talk therapy, “If you want to get over an anxiety disorder, do graduated exposure. But sit down and relate to me or love me like your mom and dad? There’s no evidence for that.”

MORE: Q&A: A Yale Psychologist Calls for Radical Change in Talk Therapy

For patients seeking help for serious problems, old style talk therapy typically isn’t helpful— and for depression, ruminating on the possible unconscious causes of distress can actually make it worse.  While long term therapeutic guidance is needed in some cases, it’s not realistic to expect insurers to cover ongoing talk sessions for those who aren’t severely disabled by chronic mental illness.

By ignoring these facts, Gottlieb is missing the most important issues. Psychotherapy doesn’t have an “image problem”: it has an evidence problem. The treatments provided by most therapists are not those shown to work and the treatments shown to work are hard to find because therapists don’t practice them, since instead they instead want to “go deep”  like Gottlieb does.

In a Q&A with the Association for Psychological Science, Kazdin described the problem this way:  “Most of the treatments used in clinical practice have not been evaluated in research.  Also, many of the treatments that have been well established are not being used.”

Indeed, one commenter on Gottlieb’s piece presented the situation far more personally:

If therapists want to attract patients, perhaps they should focus less on their “brand” and more on learning the newest, most effective techniques for treating mental illness.

For example, I have serious OCD. I spent more than a month on a fruitless search for a new therapist who practices ERP (exposure and [response prevention]). It is the only treatment recommended by the Obsessive Compulsive Foundation and other organizations, and it is the treatment with which I have had the most success. And yet, here I am, in a city with perhaps the highest number of therapists per capita, and I am unable to find an ERP therapist who takes insurance. Instead, I’ve encountered therapists who claim to treat OCD with everything from traditional talk therapy and hypnotism.

This patient is far from unique:  as someone who writes about mental illness and has suffered from depression and addiction and lives in New York City, I myself have had the same problem when seeking evidence-based treatment other than medication.  I have contacts with the world’s leading experts on research on these disorders— but when I try to find a referral for myself or a friend, I’m often stumped.  Imagine what it’s like for the average seeker of mental health care outside of a big city and far from any academic center.

If therapists like Gottlieb want to attract patients, they need to consider that sometimes the problem isn’t the branding, but the product itself.

25 comments
SidSmith
SidSmith

I'm familiar with Gottlieb and not surprised that she went into counseling as a profession. That said, her example is interesting to me because where I'm from, there is a severe therapist shortage. Only a few therapists treat the issues I have (PTSD, ADHD), and none took my insurance. Now, I'm living in one of the largest cities in the world, and the issue here is cost. Many therapists professing to specialize in treating my issues don't take insurance, and charge upwards of $500 per session. This is not affordable to the average working-class person.


Since age 10, I've tried multiple types of therapy, including the much-touted CBT, and nothing has worked. As mentioned in the article, I think therapy actually made me worse, but interestingly, CBT did the most damage to my mental state by far. Many patients with MH issues that are more functional than mood-related, like me, report that therapy does them no good, and many of us struggle to find medication that works as well, both because the types of meds that work are so narrow in scope, because many are scheduled, limiting the number of doctors who prescribe them, and because of cost. So many people think that folks with MH issues are simply stubborn, wallowing, and/or refusing treatment, when in reality, many of us have thrown thousands of thousands of dollars of good money after bad and are actually worse off for it.


The mental health care system in America is broken. No one therapist or well-meaning clinician can fix it. Everyone has to want the change and work together to make it happen, and the mentally ill are not most folks' favorite people, so I don't expect that to happen in my lifetime. 

BettyD
BettyD

This is only one side of the story.  Jonathan Shedler (The American Psychologist, 2010) published a meta-analysis of 160 studies documenting the effects of psychodynamic therapy (the kind maligned here), which showed that it produces LONG TERM change unseen in cognitive behavioral methods.  As a patient as a therapist I can attest to the life-enhancing change that this method has brought me, yes, over time, not through instant gratification.  What has instant gratification ever brought anyone?

LisaKoopman
LisaKoopman

I went to someone for a few years. She never ever said anything. Only me talking. One day she she said that I was going the wrong type of therapy. :-/ I was so angry. The time wasted. Spilling my guts. Not one word of advise. Not one. 

MelodyBakerRamdon
MelodyBakerRamdon

I think you'll see this starting to change with the younger generation of therapists who haven't yet been practicing for twenty or thirty years and who aren't so set in their ways.  As a therapist myself, I know that learning how to implement some of the evidenced based treatment protocols often only requires attending a two or three day training or reading and studying a treatment manual.  You might not deliver the treatment expertly the first few times, but like everything else it gets easier with time.  All it takes is a willingness to learn.

tomcloyd
tomcloyd

Excellent, really excellent. "If therapists like Gottlieb want to attract patients, they need to consider that sometimes the problem isn’t the branding, but the product itself." Yes! I'm a therapist who treats PTSD and DID, always striving to bring to the consulting room interventions I can support, as much as possible, with research. This rankles more than few of my peers, especially the ones who couldn't tell a median from a mode, but the clients actually don't mind getting results, and this week. Funny how that works out!

Thanks for this fine contribution to the general discussion about the relevance of psychotherapy.

Read more: http://healthland.time.com/2012/11/27/can-branding-save-talk-therapy/#ixzz2DUV9rLQV

FrancisMulhare
FrancisMulhare

I could not agree more. Research in the last 15 yrs or so, mostly as a result of studies involving brain scans, clearly show that most serious issues are accompanied by  and probably caused by abnormalities in brain structure as well as function. For example depressives typically have an undersized and low functioning hippocampus while the highly anxious have abnormally sized amygdalas . There is no way that talk therapy is going to increase the size of your hippocampus..it is just too weak a tool. Sure some of these problems are caused by early childhood conditioning (abuse etc) as well as genes but once it becomes established in brain structure it is too late for something like psychotherapy to have a significant effect beyond helping manage the problem.

tomcloyd
tomcloyd

@Discussant Yes, and heart surgery kills people...when it doesn't save their lives. You are obviously over-generalizing. Life itself is de-humanizing. So is work, and marriage...some of the time. Shall we gratuitously disparage them as well?

The real question is how often, and why. In the case of psychotherapy, the research on psychotherapy outcomes indicates that failures do happen, but not most of the time. Positive outcomes exceed those of medicine. But that's only relevant if you're interested in the reality of the situation, and not just your polemical point of view.

tomcloyd
tomcloyd

@SidSmith Your comment addresses the issue of "access to services", which can be insufficient due either to lack of providers or to cost. I agree with you, and I'm outraged by this. This happens in large part because we insist on seeing health care as a business rather than as a service, like clean water. Other countries have found the answer, and it works: a single payor system.

tomcloyd
tomcloyd

@FrancisMulhare Sorry, but you haven't done your homework. There is no MEDICATION that addresses the limbic system issues you speak of. Van der Kolk's research has shown that exposure-focused trauma therapy DOES. The hippocampus returns to normal size and function, after therapy.

mizzbelle
mizzbelle

@tomcloyd@Discussant
Incuriousness regarding negative outcome appears a common trait among psychotherapists. They so often resort to every manner of resistance, ad hominem attack and absolutism rather rather than consider consumer feedback about their specialty's failings.   Therapist are the last people I'd seek mental health guidance, but  they can perform a terrific scornful-cult-leader affect. 


Discussant
Discussant

@tomcloyd @Discussant

For  heart surgeries, the scientific research is sound, and the benefits outweigh the risks in some cases. In cases where the surgery would be too risky, an honest doctor will inform the person up front by providing predicted success/failure rates. To the extent that life, work, and marriage are dehumanizing, as you suggest, we ought to do our best to transform them into more humane, dignified, and compassionate endeavors. Psychotherapy cropped up based on Freud's musings, is in a league of its own, and cannot be compared to these other areas of life. The benefits have not been shown to justify the risks. Psychology studies are notorious for being riddled with shady data practices, including confirmation bias, file-drawer effects, allegiance effects, etc. And the (unfalsifiable) anecdotes/”cases” don’t cut it either, and don’t distinguish therapists from motivational speakers, psychics/palm readers, gurus, mystics, cult leaders, or other snake-oil vendors that prey on vulnerable clients while maintaining the support of enthusiasts full of anecdotes extolling their life-changing benefits. http://www.nature.com/news/psychology-must-learn-a-lesson-from-fraud-case-1.9513
http://www.guardian.co.uk/science/blog/2013/feb/27/psychologists-bmc-psychology
http://bigthink.com/neurobonkers/the-mystery-of-the-missing-experiments
We need to think critically before subjecting people to shady practices that profit therapists but often harm clients.

tomcloyd
tomcloyd

@Discussant @BettyD Only one of your links (the first) addresses the question at issue. The others do not. The one is itself interesting and thoughtful, but I find it flawed. 

He talks about effect "masking" as a consequence of grouping certain ways of doing meta-analyses. Masking involves effect REDUCTION; the error he needs to find is effect INFLATION, and that assertion is completely absent. 

Furthermore, he write about short-term psychodynamic therapy (PT), which is not the subject of the original article being critiqued. I could go on, but you the the idea. This critique of the original article does itself have serious flaws. 

It's curious that I should be defending psychodynamic psychotherapy, as I've never been much of a fan, and certainly don't use it. However, as elsewhere pointed out, it does embody many of the common factors that have been shown to be efficacious in studies of non-PT therapy, so why would they not be in efficacious in PT?

Your assertion of "deeply flawed", etc., is deeply exaggerated. Not convincing in any way.

mizzbelle
mizzbelle

@Discussant@tomcloyd@mizzbelle
In a shadow-boxing about efficacy statistics, Mr. Cloyd entirely distorts and mischaracterizes the initial link, a first-person account of how the therapy's contrived, infantilizing framework proves harmful to some consumers.  Since it's  a candidly first-person blog, not a scientific presentation, Mr. Cloyd sets up a straw man in "evaluating"  it as an academic presentation. He diverts the discussion, perhaps in hope that others will play-on-his-playground.

Mr. Cloyd  illustrates qualities I've observed in therapists-- that they're only comfortable  prevailing, controlling interpretations and setting the agenda.  The blog essay asks how  a client surrendering herself to a false "life expert" is a path to  autonomy.  How is a regressive, parent/child relationship a road to competence?  How does the phony, contrived relationship of the consulting room, its pretend-intimacy, foster authenticity?

Search professional literature for some insight about failed therapy, you'll find almost nothing, and the little available largely blames the client. I can't respect a "science" or practitioners so seemingly afraid of negative outcome evidence.

Discussant
Discussant

@tomcloyd @Discussant @mizzbelle

Tom, since you're making a living by engaging in a practice that harms some people, I sure hope you have a very strong valid argument to justify yourself. I look forward to seeing it. And, while you're at it, please remember that the end doesn’t justify the means. The number of anecdotes about people who claim to have benefited from a practice is irrelevant in the face of dehumanizing or unethical means to that “benefit.” Atrocities have occurred throughout history when people overlooked this principle.

mizzbelle
mizzbelle

@tomcloyd @Discussant @mizzbelle  

Speaking of mis-fire, Cloyd's rant evades the original post topic, which linked to a personal narrative about harm in therapy. That blog discussion explores the psychotherapist's tendency toward an authoritarian personality and the damage interaction with them has caused clients.

I read largely diversion, ranting, ad hominem attacks and defensiveness from the psychotherapist on this thread. In my view, he does a lovely job in bolstering a therapy-skeptic's argument.

tomcloyd
tomcloyd

@Discussant @tomcloyd @mizzbelle I'm being logically defensive, merely by replying, NOT psychologically defensive. You are not really a threat because you have no valid position, so I feel in no way psychologically defensive. It's that simple. I point out that I argue from data - client records I obviously cannot disclose. You haven't even bothered to refer to data. Thus the structure of our statements are different. I have an argument; you don't. Finally, I will provide accessible date - published in peer review journals, in another venue, far more appropriate than this. I'm already working on the write-up. It'll be a few days. Will be back with a link.

Discussant
Discussant

@tomcloyd @mizzbelle @Discussant

Tom, you've mentioned a couple times that you have data, but all I've seen from you so far is defensiveness and ad hominem attacks. The burden of proof lies with s/he who asserts a positive.  In this case the burden of proof lies with s/he who asserts that therapy is justified despite the costs and risk of harm, not with its critics. It is not the critics’ job to prove the null hypothesis. 

PS - I normally wouldn't point out someone's defensiveness, but since you're a therapist, I thought you might value the insight.

tomcloyd
tomcloyd

@mizzbelle @tomcloyd @DiscussantI do, indeed, have a low tolerance for logical mis-fires and plain ignorance. There's simply too much at stake. But then you'd know that if you were on the front lines like I am. Spend a week sitting beside me and you'd have a rather different perspective. This isn't a game for amateurs or armchair critics. I actually have data supporting my positions; where's yours?

tomcloyd
tomcloyd

@mizzbelle @tomcloyd @Discussant You do not persuade, either. Mere ranting may feel good, but it doesn't address the issues. "...so often..." - really? Your data, please....

tomcloyd
tomcloyd

@Discussant @tomcloyd More extravagant over-generalizations, with no supporting evidence. Not persuasive. This is my field, not yours. If it were fundamentally fraudulent, I'd have left it long ago.

Your links are interesting. They address egregious fraud in research (which is rare), and the non-reporting of negative results, which is not. Re: the latter - journals don't want to publish such, unless the given study indicates a major challenge to an existing paradigm. That's understandable. We already have a flood of published research, with which no one can keep up. Publish all the negative findings and the situation would be far worse. For this problem, I have no solution at the moment, other to point out that not publishing negative findings is not the problem you think. If p=.05 for an effect, then it's probably not an error. If the effect size is non-trivial, it probably worth looking at further. Over time, the truth will out. This system does work.

Most important to this discussion is that your link in no way addresses the issue at hand: the legitimate and demonstrated efficacy of psychotherapy. You evidence a complete lack of familiarity with the relevant research. That's convenient, as that leaves a large vacuum into which you can insert your rants. Not persuasive, I'm afraid.

The issue of psychotherapy's efficacy is, of course, entirely legitimate, as is the cost-benefit question. I'll address both, elsewhere, in a more appropriate venue, and bring a link back here. I'm more than willing to be held to my own standards, and support my assertions.