Episode 208: What People Want From Therapy
Rakeen Prince, BA, Linda Michaels, PsyD, MBA, David Puder, MD
In today’s episode we interview Linda Michaels, PsyD, MBA, a clinical psychologist in private practice in Chicago. She is chair and co-founder of the Psychotherapy Action Network (PsiAN), a non-profit that advocates for quality therapy. She is also Consulting Editor of Psychoanalytic Inquiry, Clinical Associate Faculty at the Chicago Center for Psychoanalysis, and a fellow of the Lauder Institute Global MBA program. She has published and presented on the value of psychotherapy, the therapeutic relationship and technology, and the public narrative about therapy. She has also been interviewed by the New York Times, NPR, the John Oliver show, and other national media on the value of psychotherapy. Linda has a former career in business, with over 15 years of experience consulting with organizations in the U.S. and Latin America.
Additionally, she is the co-editor and author of a new book, Advancing Psychotherapy for the Next Generation: Humanizing Mental Health Policy and Practice.
Psychotherapy Action Network (PsiAN): PsiAN strives for a world in which psychotherapies that create lasting change are universally available to those in need. PsiAN has initiatives aimed at mental health professionals, policymakers, and the general public. As part of reaching the public, they conduct research to understand what people want from therapy.
What Do People Want From Therapy?
Therapies of depth, insight, and relationship have been missing from, if not pushed out of, the public conversation on mental health treatment. After decades of attack from multiple fronts, these therapies are misunderstood, undervalued, and overlooked by the general public. In order to address this challenge and change this trajectory, we must start by listening to the public and understand their needs, values, and preferences about therapy. Dr. Michaels and colleagues conducted an extensive research project, leveraging qualitative and quantitative tools and techniques widely used in the corporate world, focused on “listening” to the public and understanding what people want and need from therapy.
It’s indisputable that therapies of depth, insight, and relationship are highly effective. What we know now is not only that these therapies work, but that they resonate with a large segment of the public. We learned that many people intuitively know there is more beneath the surface, believe that therapy is a process that takes time, and are willing to make that investment. The research also provides a blueprint for communicating the value of depth therapies to the public, grounded in what we heard from the people themselves, based on four key messages: feeling heard, the ability to make changes and choices, recognizing that therapy is worth the effort, time, and investment, and addressing the root of the issues. These considerations guide ongoing engagement with the public and inform future research endeavors.
What Do Stakeholders Within The Industry Want From Therapy?
Stakeholders in the field include insurance companies, pharmaceutical companies, public policymakers, academics, and various external influences.
Insurance companies: Want to pay for the cheapest and fastest intervention.
Pharmaceutical companies: Want you to buy their products and psychiatric medications.
Public policymakers: Want short-term cost containment. Cost containment is about finding ways to save money and reduce spending.
Academics: Want to publish studies as quickly and often as possible. Meaning, they tend to favor short-term protocols, which isn’t an accurate reflection of how therapy is actually delivered in the real world.
Technology companies: Newer entrants that are marketing technology products and apps directly to consumers are seeking to grow rapidly to satisfy investors.
But What Do People Want From Therapy?
To better understand themselves and to get to the root of their issues
Skills and coping strategies
Talking to someone without feeling judged or ashamed
How Has Therapy Changed Recently?
Misconceptions and Influences in Mental Health Care
There is a misconception about therapy that suggests it should be brief, that it should be mainly focused on symptom management or reduction, that cognitive behavioral therapy (CBT) is the gold standard, and that newer medications are significantly superior to older ones. Additionally, emerging forms of therapy, which are now heavily advertised, such as text-based therapy and “AI Therapy” are gaining attention, adding to the complexity of navigating mental health care options.
Unraveling the Misconceptions
But where do these misconceptions stem from? Delve deeper, and you’ll find a trail leading to the influence of billions of dollars spent to shape public perceptions of therapy. The interconnected web of stakeholders, including private equity investors, Silicon Valley, and insurance companies, all play a role in molding the narrative around mental health care to prioritize profitability over genuine healing.
Access and Awareness
Despite these challenges, recent legislative acts, such as The Affordable Care Act and The Mental Health Parity and Addiction Equity Act (MHPAEA) have significantly improved access to mental health services. Additionally, the stigma around mental health has seen a notable decline, especially during the pandemic, with prominent figures like athletes, media personalities, and celebrities openly embracing therapy.
The Pitfalls of Profit-Driven Mental Health Care
However, the influx of interest in therapy has also attracted opportunistic forces seeking to capitalize on the growing demand. When mental health care falls into the hands of profit-driven entities, the focus often shifts away from genuine healing toward maximizing financial gains. This can lead to the growth of subpar products, superficial therapy approaches, and mere coping strategies masking as legitimate forms of treatment.
Insurance Companies: Balance Profit and Care
Insurance companies, in particular, face scrutiny for prioritizing short-term solutions to minimize their costs, enhance their profitability, and meet their quarterly financial targets. This short-sighted approach may result in inadequate medication dosages and limited coverage for comprehensive therapy that meets the standards of generally accepted care, ultimately undermining the effectiveness of mental health care for those who rely on insurance for support.
Navigating Toward Authentic Healing
In light of these challenges, it becomes imperative to advocate for a shift towards client-centered mental health care that prioritizes genuine healing over financial gains. By raising awareness, challenging misconceptions, and advocating for policies that put the needs of individuals first, we can pave the way for a mental health care landscape that truly supports and empowers those seeking healing and growth.
What Is Needed For Individuals To Get The Most Benefit From Therapy?
The Importance of Quality Therapy
Dr. Michaels emphasizes the significance of quality therapy in helping individuals navigate their mental health challenges. She highlights that therapy should not be seen as a one-size-fits-all approach, but rather as a personalized journey tailored to meet each person’s unique needs. Leveraging clinician expertise along with patient preferences, values, and needs are key components of evidence-based practice. Quality therapy involves a collaborative and empathetic therapeutic relationship, where the therapist creates a safe space for clients to explore their thoughts, emotions and experiences.
Building Trust and Connection
One of the fundamental aspects of therapy is establishing trust and connection between the therapist and the client. Trust allows individuals to open up and share their deepest concerns without fear of judgment or criticism. A strong therapeutic alliance allows clients to feel understood, validated, and supported throughout their healing process. Decades of evidence also confirm the importance of the therapeutic relationship - the relationship is the effective ingredient in treatment.
Individualized Treatment Plans
It is crucial to develop individualized treatment plans that address the specific needs and goals of each client. Therapy should be a collaborative effort, where clients actively participate in setting their therapeutic objectives. By tailoring treatment plans to individual circumstances, therapists can provide more effective and meaningful support. This approach is supported by the evidence base and aligns with generally accepted standards of care. Importantly, this approach is absent in the one-size-fits-all apps and self-help tools that many technology companies are marketing.
Creating a Safe and Non-Judgmental Environment
In therapy, creating a safe and non-judgmental environment within therapy sessions is essential. This allows clients to freely express their thoughts and emotions, offering self-reflection and personal growth. A safe space encourages clients to confront their challenges, develop coping strategies, and gain a deeper understanding of themselves.
The Role of Psychoeducation
Dr. Michaels discusses the importance of psychoeducation in therapy. By providing clients with information about their mental health conditions, therapists empower individuals to better understand their experiences and make informed decisions about their treatment. Psychoeducation also helps reduce stigma and promotes self-compassion, enabling clients to embrace their journey towards healing.
A Background On Therapies Of Depth, Insight And Relationship
What are therapies of depth, insight and relationship?
Depth: Probing beneath surface-level thoughts, feelings, and behaviors to identify more hidden ideas or fears that interfere with self-esteem and self-confidence.
Insight: Helping people identify and recognize repeating patterns that may have been adaptive initially, but then have held them back from achieving personal or professional goals.
Relationship: The relationship with the therapist is the most effective healing aspect of therapy. The 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.
Some examples of therapies of depth, insight, and relationship include psychoanalytic therapy/psychoanalysis, humanistic, existential, attachment-focused. These therapies both help manage and reduce symptoms, as well as pursue the more substantive and sustainable gains in relationships with self and others as well as achievement in personal and professional realms. They often contrast with structured, shorter-term treatments that have a stronger focus on symptom management and behavioral change.
A high-quality, substantial evidence base shows that depth therapies are:
Highly effective
Long-lasting
Backed by a robust, high-quality evidence base
Especially effective for comorbidities, personality disorders, chronic conditions
“Dosage” and length of treatment matter *
High effect sizes that increase over time, even after treatment stops—in contrast to high relapse rates of short-term therapy and medications
Yet, the public, and some in the policy and even clinical arenas, seem to not understand the evidence base, the effectiveness of depth therapies, and their long-lasting benefits. Understandably, many obtain most of their information about therapy from the popular press, insurance companies, and pharmaceutical advertising, which all favor short-term structured therapies for the many financial and political reasons outlined above (“Ask your doctor about CBT and meds” is a common refrain at the end of many articles on therapy).
In addition, many negative biases and outdated stereotypes about depth therapy/psychoanalytic therapy exist and persist.
“One way to conceptualize the challenges faced by therapies of depth, insight, and relationship is to think of them as a branding problem. This means centering the associations, emotions, mental models, and expectations about depth therapies—the way these therapies have come to “live” in people’s minds and hearts—as a core part of the issue. Using this perspective highlights the need to first listen to the public—the users and potential users of therapy—in order to find ways to engage with them that are meaningful, relevant, impactful, and on their terms” (p. 215).
So, based on Linda Michaels’ prior career in business consulting and consumer insights research, she and her colleague, Santiago Delboy, undertook the task of studying the general public and these questions, mental models, associations, and expectations of therapy.
Methodology
The qualitative phase included 46 in-depth-interviews, 1:1, for 30-90 minutes each. These interviews helped to surface hypotheses and themes, which were later tested quantitatively.
In the quantitative phase, they fielded an online questionnaire, with the help of a professional marketing research firm that could execute the dissemination and data collection of the survey and ensure an unbiased sample. The quantitative sample was comprised of 1535 individuals, and it was representative of the U.S. population on key 5 variables: age, gender, race/ethnicity, geographic region, and income.
Findings
What do people want from therapy:
70%: “Learning skills and coping strategies,” a focus of most manualized treatment modalities.
70%: “Better understanding yourself and the root of your issues,” a focus of therapies of depth, insight, and relationship.
66%: “Sharing your feelings and thoughts without being judged or shamed.”
60%: “Feeling heard and understood by someone who cares about you.”
66%: Recognize that therapy takes time, acknowledging that “emotional and psychological problems inherently take time to understand and resolve.”
A similar proportion believe that going to therapy is an investment that is worth making.
91% prefer a therapy that addresses root causes of symptoms, even if it takes longer, rather than only providing ways to manage symptoms.
What Do People Do Instead And What Is Their Experience With Mental Health Treatment?
Regarding actions people would take if they were feeling frustrated, anxious, or not in control of their thoughts and emotions:
58% stated that they would talk to friends and family.
57% said that they would keep themselves active and busy as a coping mechanism.
52% try to remain optimistic and think positively.
48% said they would consider speaking with a therapist.
Only 23% would consider taking medication to regulate their thoughts and emotions, and a similar percentage would search for ideas on social media.
For those who would not consider therapy
41% cited that they believe herapy is too expensive as the main reason.
If they were to consider therapy, how would they go about doing so?
59% said they would ask their physician for recommendations, highlighting the gate-keeping role that physicians may play.
53% would also look for the mental health providers covered by their insurance, which is consistent with the concerns about the cost of therapy.
Only a third of respondents would ask their family or friends for referrals.
A quarter of respondents would use an online search engine like Google.
Notably, younger people are significantly more likely to engage in these last two behaviors, although they would still start with their physician and insurance company.
Criteria for choosing a therapist?
65%: whether the therapist is in-network with the patient’s insurance
52%: office location (this has likely changed due to Covid and the ubiquity of telehealth)
50%: therapist’s personality (which speaks to the importance of the relationship)
In the single digits were things like the therapist’s theoretical orientation, their degree, their publications or website (factors which many therapists might tend to focus on).
Actual behaviors
They also researched what people had actually done to deal with mental health, emotional, or psychological difficulties. They found that about half of the sample (47%) had direct experience with therapy or counseling, almost 90% of them as an adult.
One-third of the sample had direct experience with psychiatric medications, and about 28% reported having used mindfulness/meditation or self-help books, the former being more significant among younger respondents.
People expressed interest in typical depth therapy process:
The researchers aimed to understand public perceptions of depth, insight, and relationship therapies through concept testing, which is a common tool in corporate market research. They presented a refined description of a typical depth therapy process which had been developed through feedback from the qualitative interviews. This method allowed them to gather feedback on the concept without revealing the specific therapy.
Here is part of what was read to them:
“Its main focus is on understanding and dealing with the underlying causes… People gain self-awareness and self-understanding, which can lead to new ways of seeing and handling problems in life.”
Overall, the responses were quite positive and people said this description matched what they thought of therapy. Some of the positive comments focused on the appreciation of digging deeper to identify underlying issues, its long-lasting impact, and the non-judgemental approach to the patient and their feelings.
58% stated they would definitely or probably consider this form of therapy
Awareness Of Different Types Of Therapy
66% Psychoanalysis/psychoanalytic therapy
64% CBT
42% Mindfulness-based therapy
30% Humanistic
All other types of therapy included in the survey received 16% awareness or less.
Notably, psychodynamic therapy was among the brands included and awareness was only 16%. This finding would indicate that professionals should carefully consider whether they use the phrase psychodynamic, as it has little meaning to the public. The public is confused enough as it is when it comes to understanding different forms of therapy or choosing a therapist; we do not need to add to this confusion unnecessarily.
How did people in the study compare psychoanalysis/psychoanalytic therapy and CBT?
Psychoanalysis is mostly associated with self-understanding, getting to the “root cause” of problems, being able to help people from all demographics, and being an individualized, yet expensive, treatment option.
CBT is mostly associated with changing behaviors, being able to help people from all demographics, helping people gain control over their lives, and being a relevant, effective, and updated form of therapy for current psychological problems.
However, when compared side by side, psychoanalysis appears to be perceived less favorably than CBT by the general public along most dimensions.
Discussion And Recommendations
The breadth of this research provides the most extensive dataset on people’s opinions, needs, and attitudes about psychotherapy that we are aware of. The researchers have documented what people want and hope for from therapy, and note how different their expectations are from the most common marketing messages that currently dominate the marketplace.
What the public wants and needs from therapy is well-aligned with what depth therapy can offer, and is also supported by the evidence base documenting therapy outcomes. However, the public does not know this and, in fact, maintains outdated negative stereotypes against depth therapy.
For the public to obtain the benefits it wants from therapy, these misconceptions need to be clarified.
What Is A Blueprint For Engaging With The Public?
The framework, grounded in this research, includes four key elements that should be present in any efforts to communicate with the general public about depth therapy. They represent the most important dimensions, based on people’s perceptions and attitudes, that communicate the value of therapies of depth, insight, and relationship:
Basic must-have: “Feel Heard.” For any therapy, the individual must feel heard by their therapist. They need to feel safe and able to be vulnerable, without fears of being judged or ashamed.
Key rational benefit: “Change and Choice.” In terms of what people want to get out of therapy, they want to change feelings, thoughts, behaviors, patterns, relationships, and be able to make new and different choices in their life.
Key emotional benefit: “Worth It.” People view therapy itself as a worthy experience, and that they themselves are worth getting to know and to grow.
Most differentiating factor: “Get to The Root.” People said a top benefit of therapy was to get to the root of themselves and their issues. Depth therapy stands alone in being able to help them achieve this.