Caveat Emptor: Therapy Edition

[Epistemic Status: I am not a therapist; I’ve had a couple, both of whom practiced supportive eclectic talk therapy, which probably informs my subjective feelings on this matter since I don’t think I got too much out of those experiences.]

If you hire a therapist, you know several facts about them already, because “therapist” (and the thing they do, “therapy”) is an extremely specific legal category. The license any therapist will have tells you these things:

There are something like five of these. Licensed psychologist, LMFT, LCSW, LPC, etc.

They will, as part of receiving this, have gotten something around 2000-4000 supervised hours with patients depending on jurisdiction.

Note that the term “supervised hour” is itself a bit of a term of art here. The typical minimum ratio for the supervision is one hour per week of seeing patients, which is to say, of perhaps 30 clients the therapist-in-training might talk to in a week, they might discuss 3 of them in detail with their supervisor over the course of an hour. This implies a certification guarantees perhaps ~100 hours of expert consultation on ~3000 hours of actual practice, devoted to some mix of adminstration, liability management, and actual therapeutic technique.

You can report therapists to a licensure board, and they can revoke the therapist’s license depending on whether they’ve engaged in egregious-enough misconduct. This includes stuff like sexual misconduct (no fucking patients!), exploitative dual relationships (e.g. entering business deals with clients), breaches of confidentiality, or failures of mandatory reporting.

If you have insurance, therapists can bill it! It generally does not pay them well; this is especially true if the therapist takes Medicaid, which gives Chipotle-service-worker levels of hourly compensation once you take into account no-shows and time spent outside of session.

There are laws with teeth that the therapist won’t talk about your shit to other people. Law enforcement itself (with the exclusion of mandatory reporter obligations) cannot force a therapist to talk about what his patient has told him.

These are all real guarantees, and they matter for a lot of people, especially for the emotionally vulnerable and the money-conscious.

Most therapists practice some eclectic blend of therapeutic modalities: a dash of CBT here, a bit of ACT there. Supportive talk therapy, freed of any specific modality or theory-of-change, is quite normal. (I don’t recall my past therapists doing anything that resembled any specific therapeutic modality at all.)

I suspect eclectic supportive talk therapy is the modal therapy situation, and in terms of effectiveness, “supportive conversation from a person with a credential” is likely to be similar to getting supportive conversation in any other context.

Note that “years of experience” and “type of credential” very weakly predict therapist effectiveness.

Results demonstrated a small, but significant relationship between therapist experience and internalizing client outcomes. There was no relationship between therapist experience and outcomes in clients with primary anxiety disorders. In samples of clients with primary depressive disorders and in samples of clients with mixed internalizing disorders, there was a significant relationship between experience and outcomes.

Famously, claimed modality also doesn’t predict therapist effectiveness (the famed “Dodo Bird Verdict.”)

To be clear, it matters enormously which therapist you end up with! Basically all the literature I’ve read agrees the best therapists are much much better than the worst therapists. It’s just not predictable which therapists is which using years of experience, credential type, modality, or anything else easily legible to prospective patients. Even star-based patient reviews are likely to systematically overvalue warmth and rapport as opposed to “did this person actually resolve my problem.”

That is because people frequently assume that “time spent doing a thing” equates to “practice” and it’s not. “Practice” requires that you have a feedback loop where you can discover what you did that worked and what you did that didn’t work, which allows you to improve over time. Years of experience will predict quality in only those fields where there is a feedback loop: where the practitioner is monitoring things and seeing what works and what doesn’t.

However, there’s no specific mechanism by which therapists are required to do this, especially after they’re trained: therapists have to rig up their own outcome monitoring practices and devote time and effort to feeding that information back into how they interact with patients. This takes time and effort and therapists are, frequently, starved for both time and energy. So they might do this, they might not.

There’s a saying in software-engineering-land: that there’s a difference between “ten years of experience” and “one year of experience, repeated ten times.” I think that’s kinda what we’re seeing here: therapists exist of both types and you won’t be able to see which kind they are from a “years of experience” blurb.

That means, unfortunately, that we are in a similar place with therapy as any other small service business in capitalism, like contractors or auto repair. Some therapists are quite good! Some are basically not giving therapy in any except the strictest regulatory sense. Years of experience and credential type don’t really tell you to what degree this will be true for a given person.

A pretty strong implication is that you should have a good idea of what you want from therapy before you arrive for your first session. Do you basically want somebody supportive to dish with once a week? Okay, valid. A support structure while you break up with your abusive spouse? Excellent, carry on.

But if you’re looking to deal with a specific psychological problem you want treated, like anxiety or depression or ptsd, I think it is reasonable to figure out jointly with the therapist what a reasonable timeline for improvement looks like and what their stated mechanism of change for that would be. And then figure out, in advance, what alternative approaches look like if the current approach doesn’t pan out by some particular date. (I think it is very very common in both medicine and psych for the doctor or therapist to delay the intellectual labor of “figuring out a plan B for if this doesn’t work” for as long as possible; this tendency sucks.)

And then, if the timeline elapses and you haven’t improved along whatever dimensions you care about, do whatever the next thing in your flowchart was, which possibly involves finding a different therapist. Our goal being to avoid the traditional failure mode of “you’ve been trying xyz for a year so let’s give it a few more months” since that treats everyone’s time as incredibly cheap.