Sorry, The Therapist Can't See You — Not Now, Not Anytime Soon
August 19, 2016 6:24 PM   Subscribe

"More than 43 million Americans have depression, anxiety, or another mental health condition. But more than half never get help. Recent laws were supposed to make it easier for Californians to access treatment, but many still face roadblocks, even with insurance. In this special series by KQED's The California Report and State of Health we travel across the state to find out why it’s so difficult to get mental health care." A half-hour radio special by April Dembosky. (Links with written versions of the individual stories inside.) posted by lazuli (42 comments total) 42 users marked this as a favorite
 
I had a nervous breakdown on the job about 13 years ago and was basically told to go get treatment if I wanted to keep working there. Every mental health place I tried was two months out for a new patient. I ended up just going to my internalist and to tide me over. I quit and lost my insurance before ever getting help.

A few years back my depression got really bad and I decided to try and get help - it was two months for most places but I managed to get in someone in just one month.

So, yeah. Glad I'm still alive.
posted by charred husk at 6:49 PM on August 19, 2016 [13 favorites]


Here in IL, going to substance abuse detox does not gaurentee you a bed for treatment even when you want one. So we know that 30 days /28 days programs help reduce the risk of relaspe in some adults, but we medically detox them and send then home with an appointment slip that says well, dont drink/use drugs for the next two weeks and if we have a bed maybe then. ..which completely is against the whole reason for 30 day treatment programs.
posted by AlexiaSky at 6:57 PM on August 19, 2016 [2 favorites]


I seem to have heard this piece on the radio. My parents are in the biz so I've been exposed to these issues all my life, and I can confirm that shit is extraordinarily fucked up.

Medicine more generally also has these problems, but psychiatry in particular has been hollowed out by low insurance reimbursement schedules. For a lot of people, it's just a desert. For others, they nominally have access to care but "care" is the shortest session compatible with writing a scrip, so the doctor can get on to their next patient. If they're lucky they will also have some kind of non-MD help, but being on psychiatric drugs supervised by a non-doctor is non-ideal.
posted by grobstein at 7:01 PM on August 19, 2016 [3 favorites]


Compounding this problem, people with mental disorders who are able to access therapy by and large aren't able to access the therapies that will actually work to treat their disorders quickly (ironically, unless they're in the VA system). Manualized cognitive-behavioral treatments for PTSD, depression, anxiety disorders, OCD, and insomnia are all under 16 weeks, and they have huge impacts on these conditions--in many cases, fully resolving the disorder--for most patients in that time frame. All of the gold-standard treatments for these conditions have been rigorously tested in comparison to "treatment as usual," which means, usually, unstructured talk therapy (happy to send cites on memail request), and demonstrated to be superior. In addition to the benefit to patients, the short duration of these treatments means that more patients can be seen, which would go a long way to addressing the waitlist problems. There is certainly a place for talk therapy for non-psychopathological conditions--needing support to get through a life crisis, making decisions, figuring out issues of identity, etc.--but the fact that therapists take the money of people with disorders like PTSD for years and years of weekly sessions of unstructured talk therapy borders on malpractice in my mind. Patients leave thinking that they tried, but are untreatable or therapy doesn't work. They have paid in significant amounts of time and money for little benefit. The larger problem, of course, is that most training programs for counselors/therapists don't train in evidence-based psychotherapies, which basically creates a giant workforce of clinicians who hold patients for years without demonstrable symptom improvement beyond what would be expected from the passage of time or talking to a supportive person.

For those of you looking for treatment for a mental disorder- The Association for Behavioral and Cognitive Therapies maintains a database of clinicians who identify as CBT-oriented. If you're not seeing many names in your area, contact the one(s) you are seeing, and they should be able to put you in touch with others who aren't in the database. I, personally, would also check to see whether there's an academic medical center nearby, and see if they have an outpatient psychotherapy clinic staffed by psychology residents, fellows, and/or faculty.
posted by quiet coyote at 7:09 PM on August 19, 2016 [34 favorites]


I've struggled with often debilitating depression, poorly treated over the years, and I've probably seen a therapist about 10 times total in 20+ years.

Because I am not violent or a criminal, nor am I suicidal, the state gives not a whit. I was able to get a prescription through the county mental health clinic once, and that is about the best thing I can say for the system.

My experience with your standard run-of-the-mill family practice docs hasn't really been any better. Getting to a psychiatrist? Hah. I desperately want therapy, and to get better, and to be a functional human, but I just can't seem to put the pieces together. I've had insurance for some of the time I've been sick, and that's when I've been able to make it to therapy, but I still found the health care system opaque, uncaring, and a bit oppressive. Currently uninsured because my ACA plan lapsed when I, in a depressive fugue, didn't do thing I needed to do...

Can we please reform the drug laws, cut the defense budget by 80%, automate all the drivers, and then retrain and redistribute that labor so we can better care for each other?I don't want a handout, I'd settle for just changing the incentive structure of our society so that more people will compassionately help each other in exchange for cheap consumer goods. (ignoring the elephant in the room, our wonderful healthcare system)
posted by polyhedron at 7:10 PM on August 19, 2016 [18 favorites]


I remember when I was looking for a low cost option a few years ago, every single place I tried seemed to have requirements that I couldn't realistically manage because I was depressed.
posted by dinty_moore at 7:11 PM on August 19, 2016 [14 favorites]


Psychologists and counselors in my area are abandoning acccepting insurance frightingly rapidly. Not that it would matter to me if they did acept insurance, as my insurer's copay for mental health makes seeing someone once a week financially impossible.

I've opted to go to the local university's practicum clinic. They seemed very eager to get a non-student in there, and it's very low cost. I suffer from severe, lifelong depression, and have been in and out of therapy several times over the years. The PhD candidate I've been seeing over the past year-and-a-half has easily been the best therapist I've seen.
posted by Thorzdad at 7:18 PM on August 19, 2016 [5 favorites]


I'm a... well, you know .... and I can tell you the reason you can't find a therapist: It costs money.

It costs money to train us. I estimate my training cost something like half a million dollars when you add up all the opportunity costs, like money that never got saved AND never earned interest while I was a grad student.

It costs money to pay us. Sorry. I got student loans and credit card debt like you wouldn't believe. I got chillens. I got expenses. I'm not crying poor, but I don't live The Life. I live in a fairly shitty apartment that doesn't even have central A/C and does have the occasional roach infestation. I don't know that I'll ever save up enough money for a down payment on a house. My kids go to public school and attend fairly cut-rate day care. I drive a car that cost me $1500. My wife drives a car that cost $8000. I don't buy new underwear every year. Hell, I can't even afford therapy for myself, which would be nice sometimes. I take a salary well below the fiftieth percentile for my training and experience and responsibilities. It still costs a lot of money to pay me.

Your state and local government don't wanna pay me. Medicaid will pay about $55 a session in my state. Insurers pay between $70 and $90 for the most part. Market rate is $150-$200 per session. So if you're not paying cash, your payer is not paying enough to run a clinic that isn't a total patient mill. I work for a nonprofit that subsidizes about half the cost of running my clinic, which is why I can run my clinic and not have it be a patient mill. But it irks me to know that a charity is, effectively, subsidizing major insurance carriers.

Why don't they wanna pay me?

On the one hand, mental illness is stigmatized. So paying for help for crazypeople with crazyproblems to see the crazydoctor is not high on the list of things that gets your local politician votes. On the other hand, we literally cannot get paid by government or insurers unless you are awarded a mental illness diagnosis. We cannot get paid by government or insurance to help you with your problems BEFORE they reach the level of a mental illness diagnosis. It's a lovely cycle.

On the other hand, most psychotherapy sucks. It fucking sucks. It is shitty blah blah blah chitchat talk therapy that does get you a paid friend, which is no small thing, but which does not teach you any skills to use during the 99.5% of your life that you spend outside the therapy office. You know. The 99.5% of your life in which your problems actually exist. (I offer something better, but there's no way to make the payers believe that, especially when believing that would involve paying me more.)

On the third hand, they don't wanna pay, period. Insurers make money by taking in more in premiums than they pay out in claims PLUS their own business costs. Government turns the cost of your healthcare into a political football. Neither is a great situation. Hell, I'm a fan of single-payer and I know it would suck to be a psychotherapist under single-payer. There might be less paperwork in the sense of only having one payer to deal with versus five or ten, but I can practically guarantee the paperwork would be bad -- no one like government for spending a thousand dollars to track down ten -- and there would be less money, too.

You want mental health care? Pay for it. You want someone else to pay the bill and still get mental health care? Make them pay for it. Good luck with that.
posted by PsychoTherapist at 7:25 PM on August 19, 2016 [50 favorites]


Thorzdad raises a great point- if you have a university nearby with a clinical psychology PhD program, that's a very very solid option for finding a good clinician. Clinical psych PhD students are required to get practicum hours to graduate, and they're the one's getting trained in the treatments that work. Not all practicum clinics have a cognitive-behavioral orientation, but many do. These students are very closely supervised so you have a solid chance that they're sticking to the treatment as it was designed to be delivered- it's not like getting a haircut from the student salon.
posted by quiet coyote at 7:28 PM on August 19, 2016 [5 favorites]


Depression ruined my first shot at college. The mental health "office" (it was in the same room as the nurse and safer sex office) just handed me a photocopy (with severe generation loss) of local therapists, and they expected me to pay with my mother's insurance. This was pre-Obamacare, so people with crappy or nonexistent insurance was even more likely. And the town outside of campus is not walkable, so this assumed students had a ride or a car (freshmen cannot park on campus). Anyway, several of the places I called were out of business/had switched their numbers, and the others didn't take my insurance. So their help was worse than Google in that regard.

My fiancee, an alum of that school, says other people had similarly shitty experiences with their mental health consoling.

But the sad thing is as hard as getting cheap therapy is, it is worth it, and if you're hurting, you are worth the effort. It just sucks that one of the most difficult parts of our healthcare system happens to trouble those more likely to lose their executive functioning.
posted by mccarty.tim at 7:54 PM on August 19, 2016 [5 favorites]


I posted this because it really resonated as I listened to it in the car on my drive home from my county mental-health job, where I treat people with "severe and persistent mental illness" who have no insurance or who have Medicaid. I left my private therapy practice to do this work, for a lot of the reasons mentioned in the stories. I wanted to join insurance panels, but all but one told me they weren't accepting new therapists. The one that did accept me, paid very low rates. I'm in an area where there are enough well-off people that I had cash clients, but I couldn't morally justify treating only the well-off, and I couldn't financially afford to treat only sliding-scale clients. To fix both my conscience and my bank account, I moved to government work. Which I love, but I see, over and over again, how earlier, more competent intervention before someone ends up severely psychotic, homeless, and involuntarily hospitalized could save clients so much trauma. And I listen over and over to politicians tell me that they're going to put more money into community mental health centers, and I see absolutely no extra funding for our agency.
posted by lazuli at 7:55 PM on August 19, 2016 [12 favorites]


Wow, that article on therapists not accepting Black and working class patients is very eye-opening. How messed up.

This past year, I waited six months for an appointment with a psychiatrist (after calling dozens of doctors, she was the first I found who was accepting new patients), saw her for two appointments, and then she sent me a letter dropping me as a patient. She said she wasn't equipped to deal with my mental health conditions and that I needed to find a new psychiatrist. It was while I was in a crisis program (on her recommendation!) that required me to be under the supervision of a psychiatrist; fortunately the folks there were incredibly understanding and let me keep seeing the staff psychiatrist even after I left. I felt terrible for weeks about that letter, trying to figure out what I did wrong. I wasn't threatening or noncompliant, just upset, you know, like people with mental health problems tend to be. And I'm lucky enough to have good insurance, I'm white and middle-class, and I had a good therapist and that awesome outpatient program. I can't imagine how often people in less lucky circumstances encounter a major obstacle and feel like "fuck it" to the whole concept of getting mental health help, because I was almost there.
posted by thetortoise at 8:00 PM on August 19, 2016 [10 favorites]


The earlier the better, but there's not enough money for any of the institutions charged with the wellbeing of people, all the way down the line.
posted by cotton dress sock at 8:02 PM on August 19, 2016 [1 favorite]


The earlier the better, but there's not enough money for any of the institutions charged with the wellbeing of people, all the way down the line.

Oh, definitely! It just particularly galls every time the gun-control debate takes center stage in US national discourse, and anti-gun-control people make elaborate promises to fund mental healthcare, and then don't. (I mean, I'd prefer that they enact gun-control, but I'd take increased funding of mental healthcare as a consolation prize, even though the two have nothing to do with each other. But we get neither.)
posted by lazuli at 8:25 PM on August 19, 2016 [1 favorite]


There is certainly a place for talk therapy for non-psychopathological conditions--needing support to get through a life crisis, making decisions, figuring out issues of identity, etc.--but the fact that therapists take the money of people with disorders like PTSD for years and years of weekly sessions of unstructured talk therapy borders on malpractice in my mind.

The most important factor in the success of any therapeutic relationship across modalities has been demonstrated to be the strength of the therapeutic alliance, not whether it's CBT or talk therapy or whatever else. The data just isn't as clear as you're suggesting.

And no, the therapeutic alliance has nothing to do with your therapist being your friend.
posted by listen, lady at 8:30 PM on August 19, 2016 [16 favorites]


On the other hand, most psychotherapy sucks. It fucking sucks. It is shitty blah blah blah chitchat talk therapy that does get you a paid friend, which is no small thing, but which does not teach you any skills to use during the 99.5% of your life that you spend outside the therapy office. You know. The 99.5% of your life in which your problems actually exist.

Oh my god, this is my life. I see someone twice a week (~$70/month in out-of-pocket copay, plus lost wages from missing my hourly job to go to appointments) and our sessions have turned into me saying that I'm getting awfully tired of talking about how much of a hard time I have and him being like "well let's talk about that."

On the other hand, I do believe in getting at what drives some of this stuff. It does help to better understand what's happening to me and what I'm going through. But it's starting to feel more and more like I'm just letting my therapist know when and if something bad happens, without any real tools to deal with it beyond a postmortem. It's like, shit, here's hoping it goes better next time!

My partner has been begging me to get DBT, but there are so many conflicting messages about what's effective and so on. Talk therapy vs medication vs CBT/DBT/etc. I'm confused enough as is, and there's really no good resource for figuring it out on your own. And it's hard to find a new therapist who works well with you. Plus - and I live in California - there is the whole issue of availability and cost, as outlined in TFAs. It's a nightmare.
posted by teponaztli at 8:34 PM on August 19, 2016 [4 favorites]


But it's starting to feel more and more like I'm just letting my therapist know when and if something bad happens, without any real tools to deal with it beyond a postmortem. It's like, shit, here's hoping it goes better next time!

Find another therapist. Doesn't necessarily have to be one who does some other modality. (DBT is the shit for sure, fwiw, but there, too, the relationship matters.)
posted by listen, lady at 8:35 PM on August 19, 2016 [3 favorites]


My then health plan had exactly one pediatric psychiatrist available, in a multi-city metro area of over 2,500,000.
posted by zippy at 8:41 PM on August 19, 2016 [1 favorite]


I'm getting out of psychiatry. For the exact same billing code, I get paid less than a medical person doing the same amount of work. It means I'm expected to see about 30-50% more patients a day than my new co-workers in the medical side. I don't even know how the talk therapists (mostly LCSWs in my group) do it, except they aren't expected to see quite as many each day.

That said, the short-term therapies like CBT and other goal-directed therapies - I'm not sure how often they're really taught in talk therapy programs. About two of the LCSWs I've worked with can do them, and they tend not to unless I specifically request it for a patient. No one's got DBT or EMDR training (the latter is almost prohibitively expensive).
posted by cobaltnine at 9:10 PM on August 19, 2016 [1 favorite]


"My experience with your standard run-of-the-mill family practice docs hasn't really been any better. Getting to a psychiatrist? Hah. I desperately want therapy, and to get better, and to be a functional human, but I just can't seem to put the pieces together. I've had insurance for some of the time I've been sick, and that's when I've been able to make it to therapy, but I still found the health care system opaque, uncaring, and a bit oppressive. Currently uninsured because my ACA plan lapsed when I, in a depressive fugue, didn't do thing I needed to do..."

-posted by polyhedron is ALL OF IT EXACTLY. Needing help when you can't help yourself and you are broke, and broken is exhausting and impossible and so we just...wait for it to be over I suppose? I sure don't know.

And, PsychoTherapist, this is the other side of the problem. It's heartbreaking. Also, thank you for sharing, it's important to remember it's awful for everyone.

There is exactly nothing in the center of that Venn Diagram, sadly. Ugh.
posted by metasav at 9:13 PM on August 19, 2016 [4 favorites]


That said, the short-term therapies like CBT and other goal-directed therapies - I'm not sure how often they're really taught in talk therapy programs.

My MFT program taught CBT, though it was presented as, "You need this skill, because it's helpful, but mostly because this is what insurance will pay for." Which is really one of the reasons I chose my grad program; they seemed to understand that therapy was a business, and that various boxes needed to be checked for payment, and that insurance companies cared less about "Is this patient better?" than "Did you do an evidence-based intervention?"
posted by lazuli at 9:14 PM on August 19, 2016 [4 favorites]


The most important factor in the success of any therapeutic relationship across modalities has been demonstrated to be the strength of the therapeutic alliance, not whether it's CBT or talk therapy or whatever else. The data just isn't as clear as you're suggesting.

If you're talking about the dodo bird effect, it is true that when you lump all patients together regardless of diagnosis, therapeutic alliance matters most.* When looking at specific conditions, results are different. It is pretty darn clear, for example, that exposure and response prevention works better than talk therapy for OCD, prolonged exposure works better than talk therapy for PTSD, and so on. The dodo bird paper was written before a lot of these treatments were manualized, tested, and in widespread use among clinical psychologists. Regardless- CBT is a short-term treatment. Even if you assumed that both talk therapy and CBT work equally well for a given condition, if you are going to choose between an indefinite (probably multi year) course of talk therapy versus a few months of CBT and get the same results, CBT seems like a pretty clear choice to me from both an individual patient perspective and an access to treatment perspective.

*Actually, it matters less for CBT than for other treatments, probably because it's much more structured
posted by quiet coyote at 9:31 PM on August 19, 2016 [7 favorites]


Yeah, and long-term outcomes tend to show that CBT works really well for short-term gains. CBT protocols have shifted to examining "schema," which is CBT jargon for "early childhood experiences." The longer any one modality lasts, the closer it gets to other modalities, which leads me to believe that the most effective interventions are those that are shared among the most modalities.
posted by lazuli at 9:39 PM on August 19, 2016 [3 favorites]


CBT is better fit somethings, DBT for others, and psychotherapy for different things. Relationship seems to matter the most, followed by using the right modalities with the right type of problem. EBT and CBT have high rates of success with phobias, simple PTSD (one event) but much less do with severe OCD and complex PTSD ( CBT is useful, but straight CBT approach just isn't enough . In fact in OCD a pure CBT approach can increase checking behaviors over time. DBT is great for emotional regulation problems, but not really aimed for people with disassociation who tend to rationalize to begin with. DBT also doesn't work to well with OCD because the constant monitoring of self can reinforce checking behaviors.
Motivational lnterviewing is great for non treatment ready individuals addition to general life changes.


There is no one size fits all to therapy. But insurers
Pay CBT, DBT or no money.

Personally I think that skills based therapy is important, but it's not something I've studied much, and not in vogue for reasons until inpatient level.

It almost cost 70,000 to get my master's. It is a professional job that should be paid well, bit insurance doesn't want to pay at all, wants pepole to be formulaic, will only approve in short amounts of time.
posted by AlexiaSky at 9:50 PM on August 19, 2016 [11 favorites]


Yeah, my therapist gave up on taking insurance, it was a huuuuuuuuuuuuge pain in the ass.
posted by jenfullmoon at 11:31 PM on August 19, 2016


DBT is great for emotional regulation problems, but not really aimed for people with disassociation who tend to rationalize to begin with. DBT also doesn't work to well with OCD because the constant monitoring of self can reinforce checking behaviors.

Well, I'm screwed.

Anyway, I had no idea insurance caused so many problems. I went without insurance for a long time, and was able to get therapy at a free clinic until the ACA expanded Medicaid coverage - which was good except that it made me ineligible for free services without prividing an alternative. I ended up paying out of pocket for a while, which ran me pretty ragged. But what do you do when you really, really need support?

It wasn't the free clinic's fault, and anyway, at least they served working class people of color. What a nightmare. That article about race and class is the most upsetting of all. Jesus.
posted by teponaztli at 11:38 PM on August 19, 2016 [1 favorite]


Hell, I'm a fan of single-payer and I know it would suck to be a psychotherapist under single-payer. There might be less paperwork in the sense of only having one payer to deal with versus five or ten, but I can practically guarantee the paperwork would be bad -- no one like government for spending a thousand dollars to track down ten -- and there would be less money, too.

Are you sure about that? I know quite a few therapists/psychologists/MSWs - some in private practise and some paid by our single-payer system (either at an institution or private practise that only bills the government) and none have ever complained about low pay. The average is stated to be $77,000, but I personally don't know any that aren't getting over $100,000. Billing the government is done quickly online, usually by the practionar themselves or the receptionist (so, not even a separate job like in many American medical offices).
posted by saucysault at 12:21 AM on August 20, 2016 [2 favorites]


In the early 90's, my two inpatient stays at a private psychiatric hospital each lasted three months and cost my parents' insurance company about half a million dollars. In those days, I had scads of treatment. I had eating disorder clinic, a psychiatrist, a personal therapist, a family therapist, a stay at a residential treatment facility, and an actual treatment team that took my medical and psychiatric needs into account.

Fast forward to 2010ish. After a suicide attempt I called over a dozen psychiatrists in the area only to be told that the earliest I could see either an intern or a psychiatric nurse practitioner was four months out. My psychiatric emergency room visit resulted in a 10 minute interview with a resident and no referral. The local counseling conglomerate only has TWO therapists out of over 100 that take my insurance--which is MEDICARE. And I've already seen one of those therapists. Her shitty documentation got me kicked off of disability. Upon calling an outpatient treatment facility I was informed that they only take patients from psychiatric emergency referral. When I told them I'd been to the psych emergency room twice they seemed a bit baffled as to how I had not been referred. And last but not least, I was on a waiting list for over three years to get social services. The social worker showed up once and then missed several appointments. I finally wrote to my local NAMI chapter which happens to be run by a close friend of my father's and she basically said that I was shit out of luck and I should maybe consider going to the bipolar group run by bipolar people with no therapist present.

Needless to say, I have not had treatment for my bipolar disorder since 2008.
posted by xyzzy at 12:31 AM on August 20, 2016 [3 favorites]


It sucks to be a patient under single-payer. I was once put on an 18-month waiting list for therapy, for an urgent situation. (I could have gone for group therapy, except that took place at 3pm on [iirc] Wednesdays.)
posted by cotton dress sock at 4:14 AM on August 20, 2016


In a couple of weeks I'm going to my first appointment with my next therapist. In my mind, I'm already going over the arguments. I want to do cognitive behavioral therapy. I have a particular goal in mind, coping with PTSD that's affecting my health. Talk therapy has failed to help repeatedly. CBT seems like a no-brainer.

Of course, I've done the same song and dance routine with my last two therapists, and they've both said, sure, let's do some intake stuff first, and then before I know it we're a couple of months into talk therapy, and when I ask about cognitive behavioral, they say they're incorporating it among a variety of other techniques, which just coincidentally look exactly like talk therapy.

(My last therapist literally said, "We are doing cognitive behavioral therapy," with a bewildered look, in the middle of a completely traditional talk therapy session.)

So yes, my previous experiences with therapists are causing me to have anticipatory anxiety about talking to my therapist about cognitive behavioral therapy.
posted by MrVisible at 9:09 AM on August 20, 2016 [1 favorite]


CBT is a type of talk therapy, just one that focuses on changing the client's thoughts and behaviors. If there are specific types of interventions you want (homework, worksheets, whatever), it might be helpful to be more specific with your therapist.
posted by lazuli at 11:58 AM on August 20, 2016 [3 favorites]


CBT is only really a type of talk therapy to the extent that both involve talking. A CBT therapist should be able to tell you a week-by-week plan for the treatment, exactly how the agenda for each week will target the mechanisms maintaining the disorder, and a narrow range of how many weeks it will take to complete. They should also be systematically tracking symptoms week-by-week to understand whether treatment is working. It's true that you can incorporate CBT skills into regular talk therapy, but really, that's not necessary in most cases when treating an adult for a specific mental disorder because there are already week-by-week manuals that have been rigorously tested- why re-invent the wheel or water down what works?

Especially for PTSD, why expect a patient to ask for the treatments that work, rather than just delivering them? It's unfair to expect a patient to be knowledgable enough about the options to know what to ask for AND comfortable enough--while suffering from a mental disorder--to ask for them from their therapist in the first weeks of treatment. I can think of few convincing reasons to not do Prolonged Exposure or Cognitive Processing Therapy as a first-line treatment in adult patients without, like, active psychosis. And no, it's not just a short-term gain thing- my patients schedule booster sessions because they worry they'll need it but they come back months later and still don't have PTSD. Their partners tell me it's like night and day. This is supported by the research on long-term benefits of these treatments. I've also done talk therapy, and I stopped doing it because 1) I learned more about CBT and read more of the comparative research and 2) my patients didn't get better.
posted by quiet coyote at 5:28 PM on August 20, 2016 [3 favorites]


I should say, I can think of few reasons to not RECOMMEND those treatments to patients as what works best for most patients. Treatment decisions should absolutely be made in collaboration with the patient, who knows himself/herself best.
posted by quiet coyote at 6:18 PM on August 20, 2016 [3 favorites]


This is why I do online therapy. It's expensive and I pay out-of-pocket, so it's not necessarily accessible to lower income people, but it's significantly cheaper than traditional therapy and supposedly equally effective. I think this is the direction therapy is headed, especially because making time to drive to recurring appointments that might not be close to work is something a lot of not-rich people can't do.
posted by a strong female character at 8:39 PM on August 20, 2016 [2 favorites]


Being an amateur (and eventually student) of psychology, I did have expectations that therapists putatively offering CBT would deliver the therapy I'd read about. Over the course of my now middle-aged life, I've seen ~7 therapists claiming to provide CBT, with a range of training backgrounds (four of them were clinical psychologists). None of them did.

In almost every case, what ended up happening in the therapeutic space was a series of meandering conversations, most of them driven by whatever happened to be relevant to me on that particular day. (My answers to the question, "how are you?" seemingly being enough to throw them off. I suspect it's difficult for even trained therapists to resist the norms of ordinary conversation, maybe there's a sort of regression to the mean... ) I got some encouraging words here and there; occasionally, a pointed question (which I most appreciated). I was treated to the odd monologue. Sometimes, I happened to be feeling just dandy on that day, and felt compelled to produce an emotion or experience for the sake of the theatre of confession. In part because no one was keeping track of where we were supposed to be going, and what we were supposed to be doing.

I got the most out of therapy when I was over 30, had a firm view on what I needed to get from it, and drove the conversation in that direction. Importantly, I also wasn't as bad off as I'd been in the past, the issues were completely situational. If you need to be in that kind of place to benefit from therapy, something's not right.

I think that in those private rooms, on their own, over time, there's a lot of room for therapists to settle into idiosyncratic patterns -and to confirm their own beliefs about the value and ideal processes of therapy, its outcomes, efficacy. Patients aren't usually in a position to challenge them.

I appreciated the processes at one clinic in particular. There was a scheduled review at 6 and 12 weeks, checking progress against the specific goals that had been established in the first couple of appointments. I was informed several times (at the beginning, and as we went) that if I felt things weren't going well for whatever reason, I had the option of speaking (privately) to another therapist or the coordinator. I believe the therapists also met biweekly to discuss cases. I think this is as good a setup as anyone could hope for - therapists are held in check by - and have support from - their colleagues, and clients have an out. Much less of a chance of the therapist going off into their own orbit, compared to those working on their own, or of clients experiencing any of the dangers of submitting to someone else's (anyone's) moral/scientific authority while in a vulnerable state...

tl;dr agree with this

It is shitty blah blah blah chitchat talk therapy that does get you a paid friend, which is no small thing, but which does not teach you any skills to use during the 99.5% of your life that you spend outside the therapy office. You know. The 99.5% of your life in which your problems actually exist. (I offer something better, but there's no way to make the payers believe that, especially when believing that would involve paying me more.)

Curious, what sort of thing do you offer? (And isn't skills acquisition supposed to be the B part of CBT?)
posted by cotton dress sock at 6:37 AM on August 21, 2016 [2 favorites]


CBT is good for some people and some problems. It is especially good for people with depression who have trouble with self-reflection. It can be very very bad for people with depression who are already very into rumination.
posted by hydropsyche at 7:03 AM on August 21, 2016 [3 favorites]


I guess, citation needed? Rumination is very characteristic of depression, it's thought to be a major mediator of it. The CBT of the manuals has been shown to help with depression. Not at all sure about other kinds of CBT...
posted by cotton dress sock at 7:16 AM on August 21, 2016 [2 favorites]


I appreciated the processes at one clinic in particular. There was a scheduled review at 6 and 12 weeks, checking progress against the specific goals that had been established in the first couple of appointments. I was informed several times (at the beginning, and as we went) that if I felt things weren't going well for whatever reason, I had the option of speaking (privately) to another therapist or the coordinator. I believe the therapists also met biweekly to discuss cases. I think this is as good a setup as anyone could hope for - therapists are held in check by - and have support from - their colleagues, and clients have an out. Much less of a chance of the therapist going off into their own orbit, compared to those working on their own, or of clients experiencing any of the dangers of submitting to someone else's (anyone's) moral/scientific authority while in a vulnerable state...

Checking progress against one's goals is so important, and something I don't see happening very often. And checking in with colleagues is really important -- it's required for therapists who are pre-licensed, and encouraged for licensed therapists, but I think it should be more than "encouraged." On the other hand, it can be really difficult to have a consultation group if you're in solo private practice, especially if you're in an area without a lot of other therapists (or without therapists interested in doing a consultation group).

Which I think ends up with exactly what you're talking about, with things often getting idiosyncratic with any given therapist. There are ways of pushing against that -- strict therapy protocols is one way, meaningful ongoing supervision/consultation is another, and I'm sure there are other ways, too -- but a lot of it also, I think, comes down to the therapist not buying into the seduction of thinking they have all the answers or knowledge required. And the larger percentage of the time they're the one being paid to give help rather than ask for help, the bigger that seduction becomes.
posted by lazuli at 7:46 AM on August 21, 2016 [3 favorites]


My only citation is terrible things I have witnessed happen to people I care about. And I understand that the default response is to blame the practitioner not the therapy modality. And that's fine. But if we are constantly telling depressed people that all they need to do is go do CBT and they'll be okay, but there's no way to find a therapist who is doing CBT "properly", then I'm not sure what the point is of telling people that CBT is the solution.
posted by hydropsyche at 10:02 AM on August 21, 2016 [4 favorites]


Yeah, agreed there. I don't think it's a problem specific to individual therapists, I think there probably needs to be some kind of reform, maybe along the lines lazuli suggested. More support and supervision for therapists, maybe, on the one side, and just more damn money for the care of people in mental anguish on the other.
posted by cotton dress sock at 12:02 PM on August 21, 2016


Yeah, CBT destabilized my already obsessive brain and didn't do anything to touch the reasons why I am depressed. My main beef with it is that health care systems here in Canada only offer CBT. The first therapist I saw said I had 15 sessions and I should be better by then. CBT didn't do anything to help the years of abuse and the dissociation factors and the PTSD. Getting into talk therapy and discovering the reasons why I had those cognitive distortions is what helped the most. I fear because CBT is "provable" that when people find it doesn't work for them (or they have deeper issues they aren't aware of) they'll despair that there is anything that will work. CBT can also come across as very silencing of people with PTSD who need to talk about what happened to move on. Things like CBT and EMDR are helpful for people but unfortunately the way the health care systems work is that everyone gets slotted into a box and when the offered therapies aren't working for the client it is them that get blamed as not trying hard enough instead of having the compassion to see that maybe the tools need to be changed.

Maybe it is different in the private system but in my experience of the system in Canada is that all is offered is CBT and the more screwed up you are the less the system will actually help and the more blame they will place on you. EMDR led me to be hospitalized and CBT felt like torture. And once that happened the help suddenly disappeared because the mental health system didn't know what to do with me. Instead of widening their definitions of what therapy could be they just said all therapy was making me worse and refused to give me referrals to other therapists. Instead of asking the client what would be helpful they decided on their own.

Luckily I found a non-profit therapist who helps me and doesn't stick me in a box. She incorporates all sorts of different therapies and listens when I say mindfulness isn't helpful for me. It is odd that after being in and out of the mental health system for 20 years she is the first therapist that told me she just wants me to be who I am and not take it personally when I try things she suggests and it doesn't work.

I just don't want people reading who have tried their hardest at CBT and a thousand other of the "evidence based therapies" to get discouraged and think their past hope. There are other options. Listen to your gut if something isn't working for you just like those who find "talk-therapy" unhelpful you can find CBT unhelpful too and don't let anyone bully you into forming yourself into their image to get help.
posted by kanata at 3:18 PM on August 21, 2016 [7 favorites]


Sorry, kanata, and hydropsyche - I didn't mean to give the impression that CBT is the best thing for everyone or for every condition. I'm so sorry you've had the experience you've had, I know many people struggle to find help for PTSD. BPD, too. Even simple phobias, I don't think there's a better evidenced treatment than exposure therapy for that, and I gather it's hard to find people who know how to do it faithfully. My experience has just been that even the supposedly ubiquitous CBT - which under ideal conditions is what would have been appropriate for what I was dealing with - has not been anything like it's supposed to be (on my 7 attempts). There seems to be a chasm between that ideal and what appears to be actually happening on the ground. (I'd really love to know how far off things are...)

(The therapist I found useful did Rogerian stuff. I saw her about coping with a challenging time, when I was mostly feeling all right, though; I wasn't feeling as bad as I did when I really, really needed help. I'm glad you've found someone who's been able to help you, and not made you feel that you were somehow at fault.)
posted by cotton dress sock at 4:59 PM on August 21, 2016 [2 favorites]


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