Since moving to NYC at the start of 2018 and having to go through the process of finding a new therapist again, I have felt the wrath of the mental health system come done on me time and time again. I have been dealing with mental health issues for a number of years now (see this video for my backstory) and have had my share of experience with the broken mental health system. At times I have heard people reference the idea that our mental health system is broken, but I have never come across someone really engaging with what precisely is wrong. While there are many different topics that could be analyzed when critiquing mental illness treatment, I want to focus on the institution of individual psychotherapy in this post. As I write this I made generalizations that will always have exceptions, but these overarching problems are grounded in my experiences working with a multitude of therapists with different training, in various settings, and across three regions of the US. I have spent a lot of time in therapy and I feel I am well qualified to share my opinion on where this system is falling short.
Where our treatment process of individual psychotherapy goes wrong:
- By far my biggest grievance with the mental health treatment system is the structure we use to pay for services. From the economics classes I have taken in college I have learned that the fundamental force of the economy is that people respond to incentives. In this epoch, most of the incentives that drive people center around money. Many therapists and mental health professionals have wonderful intentions of helping people, but that does not change the fact that this is how they make their living. If you spend time with a mental health provider you are expected to pay them whether you feel better or not, whether they helped you or not, whether you got the service you hoped or not. This system means therapists have no real incentive to give quality service other than being good people. Many therapists try hard out of the goodness of their hearts, but this is not always enough. Another implication of this is that therapists and other mental health providers want to keep their clients in treatment for as long as possible because then they get paid more. This results is mental health professionals trying to keep clients just sick enough that they need help and can make money off them. This is no joke as it has happened to me. Therapists do not have an incentive to help you get better if you pay them for each session. A better way to address this issue is for therapists to get paid once the client sees results. Many services do not get paid compensation until the service is complete, so I don’t see why mental health could not implement this as well. It would incentivize therapists to do their best for every single client. This solution may not solve everything, but it could at least help address this core structural problem.
- The second biggest issue in my mind is something I have noticed because I have moved twice over the course of my treatment process. With each move I have had to say goodbye to a phenomenal therapist who understood me. Because of how licensing is structured this person who you relied on for months or even years is now all of sudden completely cut off from you. It is an unfair system and I don’t see why therapists should not be able to communicate with their patients across states. In no way would it be a breach of confidentiality if it were done in a smart, respectful way. This is not an issue that applies to everyone, but many people encounter having to move at times in their life that may not be ideal. After going through the process of building up trust and understanding with someone it is hard to start over. This issue could be easily resolved if there was a national licensing exam so therapists could freely communicate with clients across state lines via Skype, FaceTime, and phone calls, to continue supporting those who have cultivated a strong relationship with their therapist and want to maintain this.
- Therapists aren’t always there for you when you need them. This is partially done on purpose for the nature of therapy to be effective, but this can at times reinforce the feelings of loneliness and lack of support that many struggling with mental illness face. To have someone who will only support you for an hour a week is not that effective. There is not enough time in therapy to communicate everything that needs to be said and for you to always have support when you need it. Of course, therapists have a life outside of their job, but at the same time it is their job to support you and it can be frustrating if you cannot get in touch with your therapist when in crisis and get the help you need. I don’t have an easy solution for this one because therapists do need their own space, but something about this harshness of having a short session and no other communication needs to change.
- There is a lot to be said for how things go down in a typical therapy session. I cannot speak for others, but I quickly learned how to avoid the hard topics in therapy if I wanted to. The best therapist I have had would push me further, but most therapists do not seem to, which is so odd to me. That should be their job! I am not one to bring up difficult topics easily and so there have been sessions where I have been dealing with something like suicidal thoughts or restricting food and these issues go untouched. One great solution that I once remember reading somewhere (I wish I could remember where!) talked about how clients should fill out a questionnaire as they are in the waiting room of their therapist’s office. These questions would allow the client to reflect on their own how their week was, what concerns they have, how their mood is, etc without having to verbal raise their concerns. The therapist can then look at this questionnaire before engaging with the client so they know the topics they need to cover and how the patient is really doing. This is something that I have rarely encountered in any form and I believe all therapists could benefit from this practice.
- Another issues is there is a lack of connection to other resources coming from therapists. I learned this by having one therapist who did an amazing job of using resources such as books, videos, feeling cards, articles, and art prompts to support the work that we were doing. She is the only therapist who has done that in my personal experience, but I wish all therapists did this. It may depend on the client whether they want this, but I found it to be an incredible way to enhance the therapy process. Simply talking has its purpose, but when this can be supported via other resources, that is when a deeper understanding of skills and issues can be reached. It is a serious flaw in the mental health system that connecting clients to other resources is not utilized by most practices.
- A frustration that is part of the process, but still deserves to be mentioned, is that finding the right therapist can be hard! Every person is different and needs something specific from their therapist. It can be a real struggle to find a therapist who you connect with. After a while, all the Psychology Today profiles look the same and trying to find someone who really gets you can seem like a huge feat. I got lucky that I have had two therapists in my life who I felt connected to, but that means all the others I have met I could feel the disconnection and I knew they weren’t right for me. There is no quick fix for this one, but the arduous process the mentally ill have to go through to find a therapist is annoying at best and harmful at worst.
- I have been privileged enough to be able to afford therapy and find therapists who are of similar background to me as a white woman, but it would be ignorant of me not to acknowledge what is faced by those who are poor and those who are minorities. This is really two separate issues, that can be intersectional when affecting individuals, with both stemming from the needs of the oppressed:
- There are serious barriers to those of lower classes who cannot afford therapy as this service easily adds app. Even with health insurance it can get very costly. Those who live in poverty can at times be the ones who need the most help but have no means of getting it. It seems like there should be a better system in place, maybe subsidized by the government or something, that provides mental health treatment for those who cannot afford it.
- There also is the issue of minority therapists not being common. There is something to be said for having a therapist who comes from your background because then they understand you on a basic, fundamental level. The lack of therapists from diverse background has potential to make it harder for those who are not white to connect with a therapist. I am not well qualified to speak on this and do not want to wrongly assume anything, but given that I have only really had white therapists I would think for someone of a different race or ethnicity this would be a serious barrier to seeking therapeutic help. This is an issue in the mental health field, as it is in all industries, that I hope will continue to progress as people realize the value of having diverse people
- Finally, this one that I am ending on is also very important, which is that no one should have to educate their therapist. I did not have to do this for the first couple of years that I was in therapy because I did not know all that much and had a lot to learn. But now that I have been part of the mental health community for a while, I have realized there are times I know more than my therapists about what is happening in the world of mental health. Not only this, but when I first started therapy it was focused on anorexia and it wasn’t until later on that I started dealing with existential depression. Since struggling with existential depression I have had to deal with many mental health professionals not understanding how I feel and what I deal with. Existential depressions is not a separate diagnosis in the DSM, but more a small subcategory among the general diagnosis of depression. To have to explain what existential depression is to therapists is ridiculous. It’s not my job to educate therapists, yet at times I have no choice. Those suffering from mental illnesses deal with enough frustration. We don’t need additional frustrations from therapists not being educated about our issues. I completely understand no therapist can be all knowing, but I sure wish they did a better job of continuing their education after school and keeping in the know about issues in the mental health community. This is not so hard as I have been in the mental health community for much less time than these therapists and have a decent grasp on core mental health issues. I still have plenty to learn, but following mental health sites like The Mighty and reading up on important issues has helped me stay in the loop as someone who in theory has less education than therapists do. It should be a basic fact that therapists have a holistic knowledge of diagnoses, such as depression, that they claim to be able to treat and to have an understanding of news that may arise that is pertinent to this community.
Now that I have let my existential depression completely come through for the writing of this blog post, I do want to end on a more positive note. For all the awful critiques I have of the system, I stuck with it long enough to find these issues because it did help me. While the system is far from perfect, I have made a dent in my eating disorder recovery and have some skills that help me cope when my depression gets bad. I only hope the system can be improved upon in the future, so more people can be helped and treatment is always a worthwhile process.
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