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.