What People Need and Want from Therapy
Advancing Access to Quality Care
The courageous kids and young adults in Ken Burns’ new documentary by Erik Ewers & Christopher Loren Ewers, Hiding in Plain Sight: Youth Mental Illness, show how emotional suffering takes root and grows in silence and shame, without regard for race, gender, identity, social or economic circumstance. Maclayn, age 11, with his fine blond hair and cherubic face, projects the lightness and innocence of a carefree child. Only his large, round eyes betray inner wells of sadness, and we’re startled as he speaks calmly and movingly about his desire to end his life when he was just nine years old. The stories of Maclayn and the others in this documentary could not be more timely, as increased suffering and need for care collide with our distressed mental health system.
Once people decide they need help — an achievement in itself — they face questions about what the best care is for them and how to find it. The Ewers brothers show us that what each individual needs can be as unique as he/she/they are. There is no one-size-fits-all, and working with a trusted professional to figure out what helps is part of the treatment process. Unfortunately, many messages about treatment are most likely to find come from companies that have something to sell — insurance companies, pharmaceutical manufacturers, tech companies, private equity firms, and venture capitalists invested in today’s gold rush of “digital behavioral health.” But, do these messages and products align with what people really need and want, especially when it comes to therapy? Will they help provide effective, long-lasting care with results that stick?
What People Want from Therapy
From our own research with the public, we were surprised to learn that, far from corporate promises of immediate results and “therapy anywhere/anytime,” a majority of people (68%) want to get to the root of their problems and increase their self-awareness and self-understanding. Burns’ documentary shows the intergenerational impacts of trauma, abuse and addiction, which are also reflected in our research, as nearly 70% understand that “emotional and psychological problems inherently take time to understand and resolve.” They told us that “therapy is an investment in oneself that is worth making” (64%), and an overwhelming 91% prefer a therapy that addresses root causes of symptoms, even if it takes longer, rather than only providing ways to manage symptoms (which would entail fewer sessions).
How Therapy Works
People are onto something here: what they want from therapy dovetails surprisingly well with what makes therapy effective. Decades of research have shown that the key ingredient in treatment success is the therapeutic relationship. Building a strong, trusting relationship with a therapist takes time; particularly if someone has been neglected or abused, they have learned to stay safe by keeping others at a distance, and thus may push others away when they try to get close enough to help. But, while many types of therapy entail working with an empathic, nonjudgmental therapist and can help provide tools and skills and symptom relief, people told us this is not nearly enough. People wanted much more: they want to know themselves, understand why they’re suffering, and develop new capacities to change their lives.
These results often come from therapies of depth, insight and relationship, such as psychoanalytic, humanistic, attachment-based, internal family systems, and relational therapies. These talk therapies reach for depth, going beneath surface-level thoughts, feelings and behaviors to identify more hidden ideas or fears that interfere with self-esteem and self-confidence. They promote insight and self-reflection, to help people recognize patterns that have held them back in achieving personal or professional goals, and identify the changes they’d like to make. This all happens in the context of the relationship with the therapist, where people can open up without feeling judged or shamed. This relationship supports the repair of past wounds and traumas, while also providing the foundation to develop new and more satisfying relationships with others and one’s self.
Therapies that Stick
Again, in preferring the benefits that these therapies offer, the people are onto something. Through the constellation of depth, insight and relationship, research shows that people can make significant and lasting changes in their lives; indeed, years after people stop these forms of therapy, they continue to improve. Research also shows a very different story for some short-term treatment approaches, such as cognitive-behavioral therapies and medications. These treatments typically address what you see on the surface — symptoms, behaviors — and thus provide surface-level relief. Relapse can be quick and common, and cognitive-behavioral therapy has been found to be 50% less effective than initially believed. And, even though short-term treatments look cheaper at first glance and fit conveniently into the quarterly earnings cycle, once relapsing and the need for subsequent treatment are taken into account, costs go up dramatically.
Regarding cost, our research also showed that concerns about affordability are the main reason people don’t seek out treatment. They are worried they cannot afford it, and they don’t know if their insurance is reliable. Even though 93% of our sample reported having health insurance, 36% don’t know if mental health treatment is even covered in their policy. This finding is unsettling, because equal coverage for mental healthcare has been the law of the land for well over a decade. Unfortunately, insurance companies and employers alike continue to exploit loopholes to avoid offering equal mental health coverage. It’s all too common for people to run into roadblocks and a host of problems when they try to use their insurance. This is heartbreaking, if not immoral: insurance company profits should not stand in the way of curing an addiction, healing the wounds of trauma, or saving a life.
“Therapy-like” apps and chatbots — poor substitutes for the real thing
Unfortunately, when you’re suffering, you’re vulnerable. And it can be tempting to click on one of ads for mental health apps that seem so ubiquitous these days, complete with celebrity endorsements. Yet, many apps don’t actually offer therapy, but rather watered-down products such as self-help exercises, unproven techniques of “therapy-like” chats using asynchronous texting, and coaching by unlicensed para-professionals. A new position paper from Psychotherapy Action Network outlines the potential promises and the very real perils of these new products. Violations of confidentiality are built into these apps, and many use — even sell — users’ data for marketing purposes. Many have been developed by computer programmers with the same agenda as those who create video games and social media platforms: to keep people using the product for as long as possible. They are also funded by venture capital where the goal is not to help ease suffering, but to develop a product or invest in a company, create a buzz, exit the investment and move on to the next. Users of these apps quickly find that what the advertising copy giveth, the fine print taketh away, and a new article in Time suggests that the online therapy bubble is already close to bursting.
Many of these products claim that they are increasing access to therapy. While access to a licensed therapist who takes one’s insurance is a critical need, corporations selling “therapy” apps and technology define access differently than therapists do. App developers are selling immediate gratification and convenience from the device in your pocket (BetterHelp.com advertises “therapy when you need it… You don’t need an appointment to reach out to your therapist. Message them anytime”). While it sounds enticing, this offer to text a therapist anytime — any time you feel stressed or anxious or upset — will likely backfire. It won’t help to create the self-confidence that people build over time in therapy, leading up to the day they can assess their emotions, goals and options and help themselves make new and better choices. Access to these newfound feelings and capacities are what people really want and need. Neither will these apps help with structural access problems in our healthcare and insurance systems.
Importantly, the purported easy access and convenience comes at quite a cost; the limited commitment involved in interacting with an app means a lower likelihood of building that all-important therapeutic relationship. So consumers pay more, but get less of the effective ingredient. One app, Bloom, seems to have reached the endpoint, where we are encouraged to “be (y)our own therapist.” Of course, you can’t be your own therapist any more than you can be your own parent. Just ask Maclayn or any of the kids featured in Burns’ film. Without an actual therapist, alone staring at our screens, we are literally being left to our own devices, which only enables the hiding and amplifies the suffering.
Advancing Access to Quality Care
The Ewers have set the stage, and now we need to push for several important changes. We need to educate the public about which forms of therapy are most effective, continue to destigmatize asking for help, and address people’s questions of how to find quality therapy they can afford. We’ve known for decades that therapies of depth, insight and relationship are highly effective, offer benefits that stick, and receive the support of many clinicians. They are even well worth it to employers that invest in mental health benefits, and can save money on medical treatments. What we know now, with our research, is that these therapies are precisely what many people in our country are looking for.
We also need broad insurance industry reform and insurance companies that follow the law. Real improvements in access will come with structural change in insurance. Insurance companies need to eliminate their ghost networksand add more in-network therapists — which would happen quickly if they paid the market rate. They need to honor the terms of their own plans, and pay for treatment that is deemed medically necessary by the treating clinician — not the insurance company’s finance department. They also need to abide by the letter and the spirit of the parity law.
What could we do with just a fraction of the billions in insurance profits, CEO bonuses, and investment dollars being ploughed into app development and advertising that go straight to the bottom lines of Google, Meta or TikTok? What impact could celebrities really make if they spoke out for therapies that create lasting change, instead of collecting their brand ambassador paychecks or virtue-signaling with PR that merely waves at messages of mental health? Indeed, the free month of BetterHelp that rapper Travis Scott paid for in the wake of the tragedy at his Astroworld concert has been deemed exploitative of the very people who suffered. And think of all the good that Venus Williams could have done had she donated $3MM to community mental health services in her hometown of Watts instead of giving it to BetterHelp.
Instead of these expenditures, we should be investing in understanding each individual who is suffering, making sense of what happened to them, and identifying what kind of treatment will help. These are proven ways to support resilience and healing; it takes time and it takes a relationship. We have to stop short-changing our youth and forcing their suffering into hiding. Our country is rich in resources and we have made astounding improvements at scale; for example, through steadfast, comprehensive reforms, child poverty has decreased nearly 60% since 1993, in every state, for kids of every race. Regarding mental healthcare, we can change and improve our treatment systems if we show just half the strength that the kids in Burns’ film did. And to see Maclayn benefit from care and grow from wanting to die to saying now that “people love me and care about me, and I’m going to have an amazing life,” should be all the encouragement we need.
Linda Michaels is the Chair and Co-Founder of the Psychotherapy Action Network (PsiAN) and a fellow of the Lauder Institute Global MBA program. She is a psychologist with a private practice in Chicago.
