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PERHAPS YOU’RE TOYING with seeing a therapist to help you cope with, say, the transition to retirement or the loss of a loved one. How can you get the best return for the time and money you’ll invest? Unfortunately, there’s no easy answer.
Early in my career, I was an academic psychologist whose area of specialty was the effectiveness of psychotherapy. I published many papers on the topic, and also presented several at the proceedings of the Society for Psychotherapy Research. In 1972, I collaborated in a study that was sponsored by the National Institute of Mental Health and led by Hans Strupp, then the country’s foremost authority on treatment outcome. Our results were ambiguous and inconclusive.
My professional interests moved on, and I departed university life after 13 years. I became a practicing psychologist, charging a fee for a treatment whose effectiveness wasn’t convincingly demonstrated by my own data.
That brings me to a fascinating article in The New York Times Magazine that was published in May and which transported me back 50 years to my earlier research. Susan Dominus’s article, “Does Therapy Really Work? Let’s Unpack That,” caught me up on what’s been going on in the trenches since I left the academy. She asks if mental health problems are amenable to the talking cure, and if psychotherapy is worth the financial and emotional commitment it requires.
According to recent research, people who received therapy reported feeling, on average, happier and less symptomatic than similar folks who didn’t seek out treatment. But improvement and increased life satisfaction are not universal—almost 50% of patients in one study claimed little or no significant benefit from therapy. Not surprisingly, our culture has become distrustful of psychotherapy. In the 2023 romantic comedy, You Hurt My Feelings, a couple who feel their two years of counseling were unproductive demand that their therapist refund their $33,000.
Curiously, all therapeutic methods produce similar results. This finding has spurred a search for beneficial techniques that the various approaches have in common, along with efforts to pinpoint helpful attributes among therapists, such as the ability to relate empathetically. Some evidence suggests the quality of the bond between the therapist and patient, rather than any method or therapist trait, is what distinguishes successful from disappointing treatment.
The two dominant therapeutic approaches—psychoanalytically oriented and cognitive-behavioral—offer prospective patients a clear choice. The many offshoots of Freudian psychoanalytical therapy emphasize childhood influences and promote self-exploration and understanding. By contrast, cognitive-behavioral methods focus directly on relief from specific complaints, such as anxiety or depression.
Psychotherapy is not a one-shot deal, like your annual portfolio review. It’s cumulative and expensive, especially if you’re entering an emotionally enriching psychoanalytically framed therapy, which progresses more slowly than the cognitive-behavioral variety. Treatment for mental health issues is cheaper in small cities and towns than in large metropolitan areas, where the once-a-week fee can exceed $200. Many psychologists in private practice don’t accept insurance, although you can request an invoice and pursue reimbursement on your own.
Psychologists, who can’t prescribe medication, generally don’t proselytize for drug treatment. But I’ll play the maverick. Psychiatric medication offers several advantages, both financially and therapeutically. Your first interview is extensive and costly, but once you’re on a regimen you may only need to meet periodically. Insurance will pay for most of your medication, often at a higher rate than it will for psychotherapy. It may take time to hit on the medication that’s right for you, which can be discouraging, and you need to be prepared for the side effects that accompany failed trials. But if you win the lottery, your improvement can be quick and dramatic.
Unfortunately, not even the recent research reviewed by Dominus has yet determined how to match individual patients with specific therapeutic approaches. Instead, you’ll have to be a wily consumer, settling on a person and approach you feel comfortable with and that fits your pocketbook.
Steve Abramowitz is a psychologist in Sacramento, California. Earlier in his career, Steve was a university professor, including serving as research director for the psychiatry department at the University of California, Davis. He also ran his own investment advisory firm. Check out Steve’s earlier articles.
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As a fellow mental health professional (MFT), I always appreciate your reflections, Steve. If I understand your article correctly, you are exploring the question of how to spend money on emotional health effectively.
Probably one of the crossover principles is to get as much possible value for as few possible dollars. Reading books is pretty cheap, talking to family and friends is often free, and using resources with which we already have existing relationships is often cheaper than starting new ones (family doctors, pastors and rabbis, teachers, mentors, etc.)
When it comes to actually doing therapy, coming to sessions well-prepared, focusing on what we can actually change, and getting the most important decisionmakers in the room can all add value.
One of my aphorisms was to tell bright capable people given what they were already bringing to the table, we would likely only add value if we were all bringing our best efforts together collaboratively. I think that is exceedingly true for many of us who follow these articles.
Such a great article and great, thoughtful comments too!
One additional observation: just as it can take time and multiple attempts to find the optimal medication(s) and dose(s), it can take time and multiple attempts to find the optimal therapeutic approach. This can be frustrating and expensive. It can be difficult to assess when it is time to transition to a new approach. One friend explained to me that they consider their different therapies like tools in a toolbox. Some situations require a hammer and others require a screw driver, etc.
I am amongst the youngest of the Boomers. I like to think of myself as the last Boomer. Certainly, you will have encountered the macho, self-sufficient attitude that many of us have. For better and for worse, I think psychotherapy and related drugs will be more universally accepted when my generation passes.