This article originally appeared at Mad in America on June 19, 2018.
Confessing to a friend or family member that you were entering therapy used to mean something. It was akin to divulging that you were embarking on a quasi-spiritual endeavor to take an honest inventory of your past, to forge a truer self, to develop a greater capacity to love, to learn to live more intentionally. It also meant to better understand and productively express your emotions, and so alleviate anxiety and depression stemming from the suppression of self.
But we live not in the age of therapy, but of “mental health interventions.” The prevailing wisdom is that people are better off managing their mental health symptoms by turning to medications and availing themselves of short-term therapy aimed at speedily correcting thinking errors and changing unwanted behaviors. This is due to several pernicious myths about what treatment is effective and what kind of psychotherapy coverage is actually available under most health plans.
Myth 1: Psychotherapy is Mainly an Over-Utilized Service by the Worried Well
From a public policy standpoint, the major concern should not be that too many Americans are indulging in psychotherapy with doubtful progress. It should be that too many of our citizens receive an inadequate amount of psychotherapy despite its proven beneficiality.
High psychotherapy drop-out rates are one of the best kept secrets in the mental health field. Data from the Medical Expenditure Panel Surveys reveal that only about 9% of Americans who enter therapy continue for twenty or more sessions. This is alarming given that the most conservative estimate of the number of therapy sessions required for 50% of clients to show short-term improvement is 21, according to Brigham Young University professor Michael Lambert.
Myth 2: Short-Term Cognitive Behavioral Therapy (CBT) is Sufficient for Most People
While short-term CBT — changing exaggerated thought patterns and harmful habits — may have its appeal to the average overscheduled and efficiency-conscious American, its benefits don’t always last. A recent study out of the University of York, spearheaded by Shehzad Ali, found that 53% of depressed clients who underwent short-term CBT relapsed within a year.
And that figure may actually inflate the number who are adequately served by this form of care. A 2013 American Journal of Psychiatry study of 341 clients who were given sixteen sessions of CBT discovered that a mere 23% exhibited sustained recovery from depression.
Myth 3: Long-Term, In-Depth Psychotherapy is an Outdated Indulgence of Questionable Benefit
Long-term, in-depth psychotherapy is making a comeback. The latest findings of the Tavistock Adult Depression Study (TADS) show that 44% of depressed clients who were provided 18 months of weekly psychoanalytic psychotherapy (i.e., dealing with difficult past/present relationships and repressed emotions) no longer presented with clinical depression two years after treatment ended, compared to 10% of those receiving standard short-term CBT, or medications.
Myth 4: People Prefer to Take Meds than Talk to a Professional
Researchers at McLean Hospital in Massachusetts analyzed 34 studies involving over 90,000 people who were asked to select a straight preference between psychotherapy or psychiatric meds to address their psychological needs. Seventy-five percent of participants expressed a preference for psychotherapy over meds.
Myth 5: Psychotherapy Coverage Just Makes Health Care More Costly
It is commonly accepted that upwards of half of the patients on a physician’s caseload have medical problems that entail a strong psychological component. And, based on a landmark study by psychologist David Lechnyr, persons not in therapy are roughly twice as likely as those who are to visit a physician for no clear-cut medical reason. Psychotherapy is simply much cheaper than avoidable time spent in a physician’s office, a hospital ER, or an MRI chamber. Analysis by Nicholas Cummings, a pioneer in the field, points to a reduction in health care costs of 20 to 30 percent above the tab of the therapy treatment itself.
Myth 6: Rising Insurance Premiums are Due to Pricey Payments to Providers
Despite spiraling health insurance premiums over the past few decades, little to none of the added revenue has been allocated to reimbursing providers of mental health care at reasonable rates for psychotherapy visits. Blue Shield of California currently reimburses a client of mine $40 for a sixty-minute session, which is about half what a midlevel psychotherapist charged in the 1980s. The Practice Organization of the American Psychological Association estimates that since 2001 there’s been a 35% drop in the amount Medicare pays for a psychotherapy visit. Private health insurers typically adopt Medicare benchmark fees and pay for psychotherapy accordingly.
Myth 7: Mental Health Parity Laws Mean that Your Insurance Will Cover Your Psychotherapy Costs
A recent report by the risk management and health care consulting firm, Milliman, discovered that mental health services are four to six times more likely to be provided out-of-network than general medical or surgical services. In Washington, D.C. alone, about 63% of mental health related office visits were out of network in 2015. Here’s what’s behind those statistics: droves of psychotherapists are unwilling to contract with insurers because of low reimbursement rates, leading to costs being shifted from insurers to clients who end up paying out-of-pocket for needed care. This means that only those who can afford it get the help they need.
All in all, it is not enough that public policy pundits push for greater access to mental health services. Alongside improving access, there needs to be renewed focus on the quantity and quality of psychotherapy the average American currently receives. Health insurers will need to reexamine their false assumptions about the effectiveness of short-term, quick-fix therapies. They will need to abide by the parity laws in ways where reimbursement rates to providers are raised to levels that keep them commensurate with those of other health care providers, so that consumers are able to locate well-trained, seasoned mental health professionals available to provide in-depth, time-intensive psychotherapy of the sort that consumers really need to achieve meaningful and lasting change.