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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.
Interesting comment. I’m a youngish Boomer myself (born 1960). My mother, now retired, was a therapist, and I’ve spent time in therapy twice in adulthood. So I myself have never felt biased against it.
I’ve been a professor long enough that I’ve taught Gen Xers, Millennials, and now Gen Zers. I’ll retire before the Alphas start matriculating. I can definitely say that there’s WAY more attention to students’ mental health issues on campus than there was when I started my career—and more awareness and openness about it among students themselves. My two daughters are Millennials, and they and their friends talk freely about their mental health problems. At times it can feel like a one-size-fits-all self-diagnosis. For me it crosses over into unhelpful when “I’m having trouble with my mental health” is offered as a reason for inability to “adult”—but the person refuses to do anything about it, such as begin therapy or talk to a psychiatrist about medication.
Hi M Plate
You are the first reader honing in on the treatment problems created by the persisting stigma accorded mental illness and its treatment. Unfortunately, it applies to psychotherapy as well as psychiatric medication. Here are two examples, one subtle and one blatant. I have frequently found that patients who might benefit from medication prefer to do so with their internist rather than a psychiatrist. And consider this. Many insurance companies choose to limit coverage for psychotherapy yet regularly cover electroconvulsive therapy (ECT). While the case is sometimes made that the distinction exists because therapy takes “so long,” this in itself reflects a minimization of the entrenched nature of many serious conditions. As you say, the stigma complication may be less troublesome among young people. For example, the older generation is more prone to say to a seriously depressed person, “why can’t you just get up in the morning and snap out of it?” Mental illness doesn’t work that way.
Steve, I’m somewhat familiar with the insurance conundrum attached to psychotherapy versus drugs and/or device-based treatment. I worked with a company that provided TMS (transcranial magnetic stimulation), which is an intermediate and often-effective stop on the way to the more traumatic ECT. The availability of TMS was slowed by the stop-start adoption of insurance coverage for it.
In my conversations with that company’s patients over the years, I found that the stigma they felt about their mental illness was compounded by something you just touched on — the persistence, and sometimes outright incurability, of depression. The battle to achieve just the ability to cope with day-to-day life was made harder by the lack of support they felt from society, including physicians and insurers.
Given the complex mechanisms underlying anxiety and depression as well as the great variability in the ability of psychotherapists, I think a 50% improvement rate, if real, is actually quite impressive.
In thinking about the effectiveness of psychotherapy it is also worth keeping in mind that treatments for physical diseases also are far from perfect in their effectiveness. A good example is that of medications for hypertension. People vary greatly in how well different antihypertensives work for them and, unfortunately, some people are extremely difficult to manage.
Hi parkslope
So thoughtful. I certainly wouldn’t argue with your 50% figure, nor your awareness that some avowedly medical treatments might succumb to that same number. Even within psychiatry the effectiveness of many treatments depends on patients’ personality attributes and behavior, and include their biological and neurological characteristics. Take electroconvulsive therapy, were a few patients enjoy relief from depression but at least as many suffer significant memory loss. Yes, the person-to-person differences in responding is (unfortunately) so very high. I know patients who swear by ECT and others who regret their consent to having ever subjected themselves to it.
I recall a statement in the NYT article. One observer said that it is practically a “miracle” that simply talking to another person can help so many (but not all!) people overcome decades of self-blame for what was actually poor parenting. Thanks for such an insightful contribution to the discussion.
Steve, thanks for another interesting contribution. Your insider’s knowledge, along with your willingness to acknowledge therapy’s limitations, are much appreciated. And your honesty and humility always shine through!
Hi Andrew,
Any therapist or psychotherapy researcher who doesn’t accept (or even realize) the limitations of the endeavor is unrealistic and probably defensive—and best avoided. A holier than thou cast to the therapy exaggerates the already hierarchical relationship between the therapist and patient, who often already believes he is one-down in life. And thanks for your support.
There is so much we do not know about the brain and how it works. I think this is why psychiatry and mental health do not always get the respect that other illnesses get. I have been reading about parts of the brain, such as the insula and it’s relation to PTSD. One article is here: https://pubmed.ncbi.nlm.nih.gov/33516458/
These studies are often done using functional MRI (fMRI) which is also linked to artificial intelligence.
Hi kt2062
Just what I often fear—a reader who has so much more knowledge than I do about a topic. When I was in training (50 years ago!) psychologists tended to overemphasize psychosocial factors at the expense of biological/neurological ones. Today the situation is almost reversed, often for good reason. Many psychiatrists today will not even offer psychotherapy. Obviously I cannot prescribe medication or authorize any other medical care, which has until recently led me to undervalue biological/neurological treatments for mental illness.I would like to think I’ve been cured of that bias. Latter in his career, Freud admonished therapists not to always believe they offer a cure but rather embrace the notion of a more modest road to self-exploration and self- education. This often leads to an enhancement of the quality of a person’s life. It wouldn’t be a “cure” per se in the same way that surgery can remove appendicitis but, as you say, the ultimate answer (and treatment) may well lie in solving the mystery of the brain’s contribution to mental illness. I think that burgeoning field is still in its intimacy but, really, how can the brain not provide the ultimate answer, whether through talk therapy or biological/neurological ones? For now, the answer for many patients appears to lie in the combination of the two approaches for best results.
We are in the midst of having a new house built…I may need a therapist before it’s over.
Self-diagnosis is almost as unreliable as psychologists’ diagnoses. I would tweak yours just a little. You could say therapy is no longer needed because you’re already into it. The real need was right before you made the decision to go ahead with it!
Steve, thanks for the interesting article and the link to the NYT article. It’s interesting that both of today’s HD articles speak about our cognitive challenges, some surrounding our use of money.
Hi Richard
And those cognitive distortions and heavy emotional baggage they carry affect
some many other important facets of life—the perception of our loved ones, our fear of the lack of structure in retirement and even how we approach our own finality.
Very much appreciate you have taken the time to read some of my articles and contribute sensitively and intelligently to the conversation.
Thanks for pulling back the curtain on something I know little about. Another great article, Steve.
Hi Nate
Always good to hear from you and appreciate your support. It takes a lot of character and humility for someone who admits he’s not an expert yet allows himself to take in something new.
Therapy is much like chiropractic treatment. It can make one feel good, but rarely lasts and both can become addictive plus there is really no cure to be defined.
That’s why health insurance tries to limit coverage for both. They can easily be abused by both patient and provider. Sad, but true.
Hi R Quinn
Always try to take in your comments because they often take a position
different than mine. I am proof, personally, that therapy—especially in conjunction with drug treatment—can have a profound impact on a person’s life. I am not sure what you mean by a lack of staying power. I believe the past gratifying twenty years of my life to qualify as extensive. I do not pretend to know nearly as much as you do about the insurance industry. But without any professional background or experience with therapy, you might want to exercise some restraint. To minimize the value of therapy and deny or limit coverage for people who suffer from mental illness is tantamount to denying insulin to a diabetic. If you read my article carefully and openly you will see I am at least not an apologist for my industry.
I don’t pretend to know clinically about the effectiveness of mental health care, nor do I assume it never works or is not justified.
I do know it was always a source of conflict between patient, provider and health coverage. In our case self insured with a large group. Making a judgement was nearly impossible so plans simply used fixed number of visit limits.
I know there were people who had sessions every week and hit their visit limit year after year. I know (correct me if I am wrong) that defining “cured” or a clear end to treatment is difficult, unlike with medical care.
Didn’t you allude to all this in your article?
Limiting coverage is not logical, it shouldn’t be necessary, but don’t you agree the left to an unlimited payment system both patient and provider will react accordingly?
Hi again Richard!
As usual I agree with a good part of what you say. But let’s face it, we’ve professionally been on opposite sides of the fence, and we’re probably a little biased (I know I am). Let me share with you some quibbles. Yes, there can be abuse, as there can be in all kinds of insurance—maybe all the more so here (as you say) because of the difficulty in defining a psychological “cure.” I’ve witnessed it among my colleagues too often. (How many of any one therapist’s patients would actually commit suicide if therapy were withdrawn?) But this is also true for many other treatments that insurance is willing to cover. Take electroconvulsive treatment. The outcome of ECT for any single patient is almost impossible to know before treatment—occasionally some relief of depression but almost always significant memory loss. Yet many insurers and often even Medicare will pay for it. Then, there is the issue of the professional knowledge of the first-line adjusters, which is often not adequate for the difficult decisions they are asked to make. I have had patients told to switch from a more expensive antidepressant to a cheaper one. Drugs are not interchangeable. Each works on a different mechanism and people don’t necessarily respond the same to the same medication. The adjuster in these instances apparently did not understand that.
Anyway, it’s okay to differ. The truth probably falls somewhere in between.
Boy, we’d sure make for an interesting panel discussion—but I would have to write my part because (despite my therapy) I still I have some leftover public speaking anxiety!
I tend on the introverted side. If i am at a party with people i don’t know, you will find me behind a rubber plant, but i had no problem speaking on stage to hundreds of people which i did many times.
A gift I wish I had!
I think your opinion is both uninformed and misguided.
Mike!
So sorry. I mistakenly thought you were responding to my article. A reader takes the time to give the writer a supportive response and the writer misplaces his own response. I profusely apologize.
No apology necessary, Steve.
My opinion may be tainted by how much I owe to my profession and my personal life. But if I may say so, it is unquestionably not uninformed.
Having managed health plans for decades dealing with the issue of medical necessity, peer review and abuse, my opinion is based on the real world. Even Medicare limits the use of chiropractic care because of the issues I mentioned.
The move in recent years to treat mental health care the same as physical care is well meaning and logical, but does not change the potential for abuse intended or otherwise.
Ineffectiveness and even abuse can occur in all lines and forms of medical treatment, from cardiac care to simple physical therapy. I believe your specific dismissal of psychotherapy and chiropractic as “addictive” reflects your own personal bias, and I stand by my comment on it.
In my opinion Medicare is wrong to lag on chiropractic coverage, as it has lagged on other coverages over the years, and there is bipartisan Senate legislation being proposed by Senators Cramer and Blumenthal to address the issue. The word “addictive” applies much more to opioid pain medications than it does to chiropractic, and anything with the potential to reduce patient dependence on opioids is worth consideration. Not outright dismissal.
Much needed piece. Thank you.
Hi Nick
Thank you. Glad you felt the article would be helpful to folks.