On the state of therapy

I recently listened to Joe Rogan’s interview with Abigael Shrier about her recently published book, Bad Therapy. Overall I disagreed with a lot of what she had to say as she does not rely on clinical experience and didn’t explain where she got her information. Most of it seemed anecdotal. Her main argument is that most therapy for children and teens is ineffective at best and generally harmful, and that therapy has made mental health worse by making kids believe that they are limited by their trauma and anxiety, and that all they do is sit around and talk about their pain. Where I disagree with her is that at least on the podcast, she spoke of cognitive behavioral therapy to be very effective but talked about it like no one practices it, and stated that most therapy today is psychodynamic and basically just wallowing. She talked about how there are no outcome measures of therapy, and no oversight. She praises CBT and DBT, but spoke as if no one practices it, whereas the vast majority of therapists use some form of CBT and DBT.

She seems to have a very limited idea about what therapy actually entails. There are different types of therapists: clinical psychologists, counselors, and social workers. I am a counselor, which means I got a master’s in clinical mental health counseling which focuses solely on the counseling process, from diagnosis to treatment to human development to assessment (what we do to assist with diagnosis and measure outcomes in therapy). Generally, we establish treatment goals with the client, work to meet them, and assess whether they were effective. We use different treatment interventions to reach that goal. What we want to see is a reduction of mental health symptoms.

Now, that is the idea, but it is not always the reality, and in this sense I do agree with Shrier. Many therapists, including me, have been in situations or are in situations where we have incredibly large caseloads and days packed with clients, at times between 8-10 clients a day. With so many clients it is difficult to keep up with treatment goals, review case notes outside of session, and do much more than offer what we call Person-Centered therapy, which is what I think Shrier says is not helpful. Basically, it is mostly listening, validating, and empathizing. This can be very helpful for most, and is the basis for most therapy. But, if this is all that is happening in the therapy room over time, it may not lead to change.

Now, I work with adults, and have limited experience with children and teens. I do find that with children and teens the main issue is generally the parents. So I agree with her when she says that therapy can be helpful for adults who want it and need it and genuinely have something to work on. But, it is less effective for kids and teens whose parents send them to therapy and who don’t make changes themselves.

I found that my knee-jerk reaction was to be defensive of therapy, which makes sense because this is what I do. She seems uninformed. Her overall impression is that therapy is basically sitting around and talking about pain. She says that exercise is more effective for depression—which I totally agree with. I encourage all of my clients to exercise. I know that there are many pieces that go into living a good life and a therapist can and should recommend that clients engage in them. She states that running errands is good for people, for sure it is good for people. Staying home all day and sitting in front of a screen is not good for anyone. I don’t know any therapists who advocate for this. Also most therapists don’t just talk about clients’ anxiety and fragelize (is that a word?) the clients through telling them they should limit their behavior. Instead, what I do and what a lot of people do is encourage exposure therapy, which is basically facing your fears.

She does make a point that not everyone needs therapy, which I agree with. She states that feeling some anxiety and feeling down are normal parts of life that we can get through. She said that therapists sometimes treat clients like “an annuity”, and that therapists can prefer “easier” clients, such as teens with a little anxiety, because their parents pay the bill and the therapist can keep the client in therapy indefinitely. I don’t think we should be using clients to make money, though clinicians deserve to be paid, just like any medical provider. If a person is not benefiting from therapy or doesn’t need it, it is the clinician’s obligation to terminate treatment or refer out. She did also make the point that therapists sometimes don’t like to treat the people that actually need it because these clients can be more difficult. I think this is true as well. Mental health disorders can make life extremely difficult and can make people who suffer from them have behavioral patterns that can be challenging for a therapist. But it is our job to work with people with mental disorders, not just people who are high functioning because we enjoy the conversation or the money.

We do need to make sure we are measuring outcomes—something that I don’t always do and need to do. This could be by periodically assessing clients’ symptoms through assessment measures. This could be by soliciting feedback from the client routinely about what is helpful/not helpful and if they feel they are getting better. This could be by routinely checking in on clients’ progress in their goals and updating/modifying treatment goals. This is where we—and I—can do better.

Shrier also downplays trauma. She shares the anecdote about how her grandmother had a difficult upbringing—losing both parents, living through the depression, and that she went on to have a family and a successful career as a judge and also was a foster parent. I think it is definitely true that people who have difficult life experiences can have happy lives, otherwise I wouldn’t be in this field. I also agree that we need to focus on resilience. But trauma impacts people differently. People who lack a support system when going through a traumatic event often develop PTSD. And by trauma, I am referring to what we call “big T” trauma—a life threatening event, sexual assault, phsyical or sexual abuse—those are not small. Shrier seems to equate these “big T” traumas with childhood teasing and normal loss of loved ones through death. Even normal losses like death of loved ones can impact people for life. Some people have significant childhood trauma and no one to help them through it, and then as adults they have additional trauma, such as sexual assault, and it is very difficult to bootstrap your way out of a life filled with trauma and no one to support you. Sometimes the only support people have is through therapy, at least to start. A good therapist will then also encourage clients to develop healthy supportive relationships with people, which is often very difficult at first as people with complex trauma often haven’t seen or don’t know what a healthy relationship looks like.

Shrier seems to discount the idea that this complex trauma exists.

So, overall, therapy can be helpful. It also is not always helpful. There are bad therapists, and more importantly, there are systemic issues in the mental health system/healthcare system that make it difficult for therapists to provide adequate care and for clients to receive adequate care. These issues include high caseloads—especially at community mental health centers which often serve the people who need therapy the most—, low pay, and low insurance reimbursement, which can lead to burnt-out therapists who don’t have as much to give. This can have disastrous outcomes for clients. Therapists do need to be paid an adequate, living wage and they also need to take care of themselves and follow ethical guidelines—starting with doing no harm and making sure treatment is effective.

And we can realize that therapy on its own without the therapist encouraging behavioral changes outside of the therapy room is not effective. Shrier is right that exercise is helpful, trying new things and striving to accomplish something difficult is helpful, and so are relationships with others. We can’t just sit in our rooms and stare at a screen and expect everything to get better if we attend therapy once a week. But I don’t know any therapists that don’t suggest behavioral changes.