Psychiatry & Psychotherapy Podcast - What People Want From Therapy with Linda Michaels

Episode Date: March 15, 2024

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. Linda 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.  Linda Michaels, PsyD, MBA, is a clinical psychologist in private practice in Chicago. She is also chair and co-founder of the Psychotherapy Action Network (PsiAN), a non-profit that advocates for quality therapy.  By listening to this episode, you can earn 1 Psychiatry CME Credits. Link to blog. Link to YouTube video.

All right, welcome back to the podcast. I am joined today with Dr. Linda Michaels. She is a SIDI, MBA, a clinical psychologist in private practice in Chicago. She is the chair and co-founder of the Psychotherapy Action Network, a nonprofit that advocates for quality therapy. She has a number of positions in academia. She works over at the Chicago Center for Psychoanalyst. and she's an editor of the psychoanalytic inquiry. She has published broadly and has been on NPR, interviewed by the New York Times, John Oliver Show. And I thought it would be great to have you on to talk about your new book a little bit. It's called Advancing Psychotherapy for the Next Generation, humanizing mental health policy and practice.

and although a lot of people try to get on the show with their new books, I came to you wanting you on the show because of the work that you're doing and some of the commonalities in our values. It seems like you value depth therapy, therapy of depth insight and relationship. And in your book, there's a section on a study that it looks like your group did the psychotherapy action network. And you were looking specifically at what people want from therapy.

So today we will talk about what people want from therapy and what you've been up to and what your study found. So what do people want from therapy? Great question. And thanks so much for having me on your podcast. I'm so glad you're doing this. It's such a great service and resource to so many of us out there. Really appreciate it. Yeah, we wanted to, you know, figure out that question, those answers to what do people want from therapy.

We were very concerned with a lot of answers that were being supplied by other industries and other forces. You know, if you were to ask the insurance company, they want to pay for the cheapest, fastest, intervention possible. Pharmaceutical companies certainly want you to buy their products and their psychiatric medications. Public policy, again, is really focused on short-term cost containment, and academic publishing is generally studying extremely short-term protocols that really don't look much like how therapy is actually delivered in the real world. And so we wanted to really understand what the public wanted in all of this. They're also, you know, we don't have to look far. You can pick up any New Yorker and see a lot of the cartoons that kind of are caricatures of

psychoanalysis or the never-ending time on the couch. You know, we know there are a lot of biases about that and a lot of misperceptions about what is actually evidence-based therapy. What does that even mean. But if you're in the general public and you are reading the popular press, you would think the only thing that exists these days are CBT and meds, because that's really the only two things that are ever mentioned in the popular press. So we wanted to go straight to the public and ask them. And my colleague, Santiago Del Bois, and I both have kind of parallel interesting career paths. We were both in the business consulting world before and did a lot of market research and consulting to companies to help them understand consumers. That, of course, was all with the

purpose of trying to market goods and services to these people, but we wanted to use those same tools to understand the public. And so we did a market research study with the public using the qualitative and quantitative research tools that we were really familiar with from our business careers. And, you know, when we just asked people, what do you want? I mean, it was kind of amazing because their answers really centered on the things that the benefits you can really get from adept therapy. They said the majority of people said the main goal of therapy for them is to better understand themselves and get to the root of their issues. That's certainly what depth therapy is all about.

They also want skills and coping strategies, which is totally understandable. And they want to talk to someone without feeling judged or ashamed. Also, very understandable. But we were very surprised that a number of the things that came out of the study actually, from the public's perspective, aligned really well with what depth therapy can offer them. Yeah, I want to go back to kind of posing the problem that we're facing, because I think you've delineated it very well. It's like there's all these forces that are driving this mindset like therapy should be short. There are certain therapies like CBT, which is the gold

standard. Whereas, you know, like every study that I see that compares CBT with another active therapy, it's pretty similar, if not equal, like indistinguishable. There are billions of dollars spent. And I think you highlight it and you're out. I'm like, whoa. I'm thinking, like, my budget is so small to try to make any impact on like people's mindsets on what actual evidence says, right? But they're spending billions of dollars to promote new medications

with, you know, there's not that much exciting to me. It's like pretty equal efficacy to older medications, right? So it's like on the podcast I like to highlight medications like lithium. I've done two episodes on that, phylproc acid, old medications that work really well. So there's tons of money being poured into direct to consumer marketing, right? Where it's like videos on news stations promoting some new medication, right? And then there's tons of medication now more and more being poured into targeting kind of a changing mindset in therapy. Like therapy with texting.

I'd prefer we don't name any names of the companies, but it seems like there's like this kind of shift that's happening really quickly, actually, where therapy is becoming more popular, but it's kind of more. simplified, it's not as depth-oriented. You commented in the book that it's like, if you want to change your therapist, it's super easy, no extra charge. Texting as therapy, AI as therapy. I don't even like I think we need to sue for the word AI therapy. Like if someone says AI therapy again, it's not AI therapy, it's AI, it's just AI. You know, there's nothing therapy about it, right? Right. So, yeah, anything else about the problem that you see? Definitely. Yeah, you hit on a lot of the big points.

I mean, it's follow the money. You know, I think things really got accelerated with the pandemic, but prior to that, with the Affordable Care Act, for example, and it was such great news that mental health was named as an essential benefit and that insurance companies had to cover it. And then we've also had on the books for many years, the law of parity, which says that insurance companies have to give parity or comparable equal insurance coverage for mental health care, similar to what they give for physical, medical,

surgical health care. And so these kinds of things really contributed, I think, to, you know, along with decreasing stigma of going to therapy, as more athletes and celebrities talk about going to therapy and getting help, which is all for the good. But I think what's happened with all of that is that it's increased the demand for therapy so much. And then the pandemic really accelerated all of this with so many people being so stressed and anxious and depressed and fearful. Demand radically is outstripped supply. And when you have a situation like that, I mean, that's blood in the water for private equity. I mean, that is kind of a beacon for private equity to say, this is an industry that we can get in and make some money on because there's such an imbalance

between the demand and supply. But yeah, the problem when we put our mental health care in the hands of private equity investors, Silicon Valley technology app creators, as we get apps, and digital products that, yes, as you're saying, try to call themselves therapy, but we have to say they're really products built for the lowest common denominator and also built to maximize profits for their investors. You know, they're not really, they may be, you know, useful tools in some ways to help some people sometimes with some of their symptoms or issues. Journaling, of course, can be helpful, you know, things like that. They may be an entree to actual therapy or a supplement or something like that, but they cannot be a substitute. When we start to say, yes, this is a substitute

for real therapy, that's when we all lose. Yeah. And, you know, it's like in the best world you have people who are thinking like, okay, how can we solve this problem on a larger level? And they're building a company to solve a problem. Unfortunately, what happens is at some point, you know, you have people who are motivated to make money or you have a lot of investment money that's been put into it and those investors are driving like, okay, how do you get more profit out of this thing? And then you kind of have this like move towards shorter form, maybe therapy or therapies that are more superficial or more coping, coping strategies, right?

Or it's like more just let's solve this current thing. It sounds more like befriending therapy or befriending, you know, kind of like the befriending controls. Not to, you know, I think there's, I think there's good people who work at those places, good therapists. So I don't want to, I don't want to say if you're working for a technology company doing therapy, you could be doing really good work. And that's awesome.

I've had a lot of patients who I'm seen as a psychiatrist. I'm seeing them as a psychiatrist, and they have a really good connection with someone on one of the more popular technology companies. Sure, I agree. But insurance, though, does not want to pay for the therapies that often work. For example, when I was a medical student, I learned that the gold standard or the board question for borderline personality sort, the answer was dialectal behavioral therapy.

And then as a resident, you know, I spent two months in a DBT partial program as a resident, you know, witnessing the groups, being a part of the groups. I, you know, bought a book on DBT. But I also started reading that there were other therapies that were just as good. Mentalization-based therapy, transfer of focus therapy, and I started reading the actual journal articles. And what was being?

practiced in reality was about, you know, you could usually get about two to three months of treatment for a client before the insurance was just like, doc to doc, no, we're not going to pay for this anymore, two to three months if we were lucky, right? Whereas in the studies, like in the study of mentalization-based therapy, which works, which the, you know, it's incredible, right? Eight year follow-ups, awesome results. Right. The treatments, though, were about a year. it's like good luck getting a year of treatment. It's just unheard of, right? And so the patient's cycle in it out of the psych hospital,

that resets their ability to do partial again. And a lot of them don't get the treatment they need. They don't get the dose response necessary for the help. So yeah, anything on those topics that you see as you've kind of looked into this or inside into the problem. Yeah, I mean, it's a huge part of the problem. for sure. I mean, and that's why I'm so grateful to the lawyers and the individuals who stood up to their insurance companies to take them on in the form of class action lawsuits for these

violations. When the huge landmark case is the WIT versus United Behavioral Health class action lawsuit, which took years and years and years to get through the courts. And with finally was won by the class of people who stood up and said, you know, United did not pay for the care that we needed. And in some cases, the class, I mean, was represented by parents. I mean, their child had died because United refused to pay for addiction treatment. And it is, it's criminal. And the reason that that the case went that way was because United was found to be making, making coverage decisions out of their finance department, not from their clinical team. Yeah, I read that in your right up here.

It was talking about how like the finance department notes or something or the audio was actually something that was released in the case. And it's like that's the decision point. And then there were some doctors that were signing off on like 50,000 or so denials. Is that where you're finding? I think the 50,000 denials was yet another example from a different... Oh, that was a different case. Okay, I don't want to mix them up. But there are, unfortunately, a multitude of examples.

You know, and we've tried to approach insurance companies and talk to them about the long-term cost-effectiveness of therapy, because there's tons of data that show, you know, if somebody gets, like you're saying, the right dosage, the right amount of therapy, the medical care, the surgical medical cost that they incur go way down. There's huge cost savings overall to insurance companies and society if people get adequate mental health care. The insurance companies don't care about those arguments because they are so focused on such a short term, a quarterly, you know, financial report, an annual report at the longest because, you know, after a year, odds are, well, maybe that person got a different job and is now on a different insurance company. So I don't have to care about that.

Yeah, I did. I was part of a study last author on this where we looked at our IOP partial. and the 12-month cost savings was $16,000. There you go. A 34.3% reduction in healthcare costs. And so this was like a cost-saving analysis. Like, yeah, if you're an insurance company, you will literally save that much money. But most of them don't want to, they balk at like,

you know, after we get past a certain amount of days, they don't want that full dose. And I'm often doing these doc-to-docs. They don't teach us this in medical school or residency, how painful this is. This is one of the most painful parts of our day is doing a doctor doctor. We're like, no, I think this patient would really benefit.

We're trying to close up this trauma. The wounds are open. We need to do this work now. They're like, I think this can be done outpatient. And we're like, no, they don't have an outpatient therapist. Good luck getting an outpatient therapist with your insurance company. It's very hard.

They don't have an outpatient therapist. They have no one to go to. They're in the middle of this work. And they're like, no, I'm sorry. We're denying you. and it's just it's rough it's really rough yeah so it's horrible and they've yeah evaluated the patient how many times in person that and also i'll say that sometimes the person i'm like so you know can i record this call um can i put you down as taking legal responsibility if something bad

happens to this patient you know can i get your full name who who's your supervisor you know, who do I write a complaint to? You know, and there are things that can be done, and I'm going to be talking about this more in future episodes. But I think that the gist of what we're talking about, though, is that therapy takes time usually. Like to get the effect size, the result that we need with most clients, it takes more time than insurance companies want to pay.

Right, right. And you know what we found in our research in our study that's published in the book, is actually people get that. People get that it takes time for a couple reasons. They told us they understand that the problems they're dealing with have taken a certain amount of time, months, years, if not generations, for these problems that they're dealing with to develop. And they also recognize that therapy as an experience,

an activity, a treatment, takes time to work. work. They get it. They understand it's not going to be a quick fix. And they furthermore said that they think therapy is something worth investing in. It's a valuable process in and of itself, and then that they themselves are worth going through the therapy process. And so if you really ask the public. I mean, sure, is there kind of a fantasy of a quick fix? Absolutely. I mean, who wouldn't want that? But they also know realistically that doesn't really exist. And they feel that they're worth, you know, getting this valuable experience of therapy. Yeah. So let's just go back one step to talk a little bit about how you collected this information. This is a large sample size. I think it's worth talking a

little bit about the like the methodology. So tell me about the, you started with a qualitative phase, then you had a quantitative phase, started with like 3,000 people, got focused down to 1,500. Yeah, yeah, we did like much research. I mean, we did a qualitative phase first to explore the themes and generate hypotheses and inform the development of a quantitative questionnaire. And we did 46, I believe, in-depth interviews one-on-one that ranged from 30 to 90 minutes each. Most of those people were sourced through our network of colleagues through psychotherapy action network, but there were no clinicians, no clinician spouses or children involved in that, no close relatives to therapists at all. And we did that phase. Then we wrote our questionnaire

And for this online questionnaire, the quantitative piece, we wanted to make sure to have a random sample of people answer that. And we wanted it to be a very large sample that was representative of the U.S. populations. So we actually hired a professional survey company to execute that. So we wrote the questionnaire, but they executed it in terms of sending it out to thousands of people that they have in their databases of people who will respond to surveys. And so, yeah, it went out to a random sample of the U.S. population, and we sent it out to over 3,000 people, and we ended up with over 1,500 valid responses, and that sample of the 15-100

or so 100 is representative of the U.S. population by age, gender, ethnicity, income, and geographic region. Great. Wonderful. Wow. I'm just curious, how much does something like that cost to hire a company like that? That piece, well, I don't know if this will sound like a lot or a little, but yeah, just hiring them to do that to execute the survey is, $6,000. Oh, okay. And so this is why you raise money for your nonprofit so you can afford things like this. And I read that everyone else was volunteering. You volunteered your time for this or something like that. Everyone involved with, yes, I do all of this pro bono, as does everyone else. Santiago and I worked on this for a long time pro bono and we wrote it up and analyzed it and everything. And actually, everyone involved with Psychotherapy Action Network does so on a pro bono

basis, which is really amazing. We've been around for six years, and just in January of this year, we made our first hire. So everyone up until now has been doing this. Yeah, volunteer. Yeah. Yeah. So, okay, so you did this qualitative study, you asked a lot of questions, look for commonalities, built the survey, sent out the survey, quantitative study. And what do people want from therapy? Let's start with some of the details on that. What do people want? Yeah. The main things that people want are top of the list. They want to better understand themselves and get to the root of their issues. Yeah, get to the root of the issues. Ninety one percent. say they prefer a therapy that addresses root causes of symptoms, even if it takes longer,

rather than only providing ways to manage symptoms. That was really, that's an impressive amount of people. That was a very, that was, that blew us away. I mean, we, in retrospect, might have phrased that question a little bit differently, but we were astounded by, yeah, over 90% of people signing up for a longer term therapy that'll get to the root. as opposed to something that'll just help with symptom management, which of course is what, you know, many medications are aimed at symptom management. Short-term therapy is aimed at symptom management, you know, and people are saying, no, that's not good enough.

That's not what I want. Yeah. Like 70% said learning skills and coping strategies. Mm-hmm. 70% said better understanding yourself and the roots of your issues. 66% said sharing your feelings and thoughts without being judged or shamed. 60% said feeling heard and understood by someone who cares about you. And 66% recognize that therapy takes time,

acknowledging that emotional and psychological problems inherently take time to understand and resolve. Right. Right. I mean, this is, yeah, out of the mouths of the public. So it was, it's pretty incredible. It's amazing support for what we call therapies of depth, insight, and relationship. And yeah, it aligns really well with what the public actually wants. It was also interesting. We asked a number of things about how you typically can hear the benefits of therapy talked about. Like, you know, therapy is to feel better about myself. or it's to live a, you know, richer, freer life and things like that. And, you know, those did not really resonate with people. We don't know exactly why, because this was a quantitative survey. We're not face to face with them to say, why did you answer that way? But, you know, I don't know if some of those things are kind of too abstract sounding or if they don't really kind of fit in the same mental space when someone's thinking about, you know, struggling with

emotional problems. I don't really know why, but I think this gives us a lot of really useful and important information as clinicians to hold in mind when we're talking with our patients or if we speak publicly, you know, that these are the messages that are going to most connect with people. This is what, how they think of therapy. And we really need to. to understand that. You know, it's interesting. Okay, the things that you said that people don't resonate with, which seem like positive, positive aspirations, I can't remember what you even just said.

So maybe there is something a little bit like theoretical about it, or it's like, it's like, what is the pain point? Get me to the core of my issues, help me overcome this. Is this going to help that? Yeah. You know, if I'm going to be spending money on this, I want this to actually do something that, can get me out of this suffering, give me over my pain. Yeah, I think so.

I mean, I think you're onto something there because, yeah, it was this stuff like, you know, more satisfied and a richer for your life and things like, people were just like, that's not, those kinds of phrases did not resonate with people at all. I think they really wanted to make changes and they knew they had problems that they wanted to resolve and maybe in some ways were kind of,

more realistic about how to get there and sort of these general positive abstract things, you know, just missed the mark. So, okay, when you talk to people about behavioral interventions and experiences with mental health treatment, what kind of things came up? Well, we found about half of the sample would say that they would go to a therapist. I'm not sure if that's what you're getting at. There were a number of people who said, you know what, I'm never, about a third of our samples said,

I'm never going to therapy. I'm just not going to do it. So I'm going to talk to family and friends first or just try to stay optimistic and active. I'm not sure if that's kind of what you're getting at. Yeah, I think this is the data that says, you know, 60% would go to friends and family, 57% said they would keep themselves active or busy as a coping mechanism, 52%.

So they would try to remain optimistic and think positively. About 50% said they would consider going to see a therapist. And 23% said they would consider taking a medication. Right, right, yeah. And right, the medications are, you know, people have a strong preference for trying non-medication. experiences first, right? Which is not the reality of what happens, right?

I would say the majority of treatment does not have therapy involved. It's mostly medication. Right, right. And which is really backwards from a couple of different perspectives. I mean, both from the perspective of what do people actually want. And, you know, we think about what is the true actual definition of evidence-based treatment. it incorporates and should include the patient's preferences, right? That's one of the three components of evidence-based practice is what does the patient want,

plus what is a clinician, you know, what does their wisdom and experience dictate? And then the third element is what's the relevant research on this issue. But, yeah, patients do not prefer to take medication. They don't. They prefer to talk first. And that also aligns with, if you do look at the evidence base on the efficacy research, that talk therapy is more effective than has a higher effect size than medications. So that makes sense as well. But right, in the real world, the practice is often medications first and often from an internist or family doctor or OB who is not specialized in mental health care or psychiatry.

Right. I mean, well, effect size is difficult to measure unless you're measuring like a head-to-head trial between therapy and medication because medications, placebo usually works pretty well, so the effect size is going to be smaller. Therapy, often the control is a weight list, so your effect size is going to be larger. But I would agree with you that we should start, most people should start with therapy, should start with exercise, lifestyle stuff. medication should be used for the more severe cases. You know, I think someone with schizophrenia, bipolar is probably going to always need to be on medication. If your depression is that which makes you, you know, suicidal, unable to get up an exercise. Yes. Sometimes a poke can be helpful. Yes. And I think that your messaging in here was not to negate medication, but to really promote the longer.

term work is where we find big changes. And, you know, there's one big study on mentalization based therapy, which followed them for like eight years. And most of the people who had done a year plus of mentalization based therapy were off medications, largely off medications during those five years of follow-up. So compared to the control group, which most of them were on medications, three or more medications for two years of the five. So the control group was largely on medications that when they had the effective therapy, they were largely off medications. And that's for borderline personality disorder. Each disorder is going to be slightly different. But I think it's so hard to get the first line to be therapy. I've worked in a couple systems where that was the case. Like no one could come see the psychiatrist unless they had a therapist. at the I worked at a

college for a while where that was the case and that was actually really helpful because then the therapist could work with them for a number of weeks maybe decide just to do therapy if they were really severe

they could get them in to see me but the way that things are now it's like you go to a general practitioner you put on a medication and then follow-up is like a year later sometimes it's like, or maybe it's three months later. And then they're not advocating or convincing the patient to do therapy.

That being said, when I was outpatient psychiatrist in a pretty busy outpatient practice, a lot of the patients didn't want to do therapy right away. And so it took some convincing often to get them into do therapy. I don't know if they're self-selecting at that point because they're in a medication management clinic. But it sometimes took a. lot of convincing. Interestingly, I had a patient, she might be listening to this. I saw this lady, I think, starting eight years ago, and I saw until I left California. I still run an IOP partial in California. I'm still the medical director of it, the men program. And so she just entered into

the program, and she's like, Dr. Puder recommended me to be here. And I'm thinking of myself, I recommended you to be here five years ago. It took you five years. Okay. Okay, let's go. But she's ready to do the work. So some people, it's like it took literally, it took like every single session. I'll usually just be like, you know, I really think you'd benefit from something really intensive, you know, like more intensive than once a week. Because some people just don't, once a week, it's just not enough to progress, right? Yeah, yeah. No, I think what you're saying is also, you know, speaks to a crucial point, which is that different people need different things and maybe at different times.

And so we can't really think there's going to be one blanket solution for everybody, one size fits all. And it's only by knowing that individual patient and what they're open to and where they're at and what they can tolerate or manage or experience. And getting somebody into the right treatment at the right time, I mean, that actually takes a lot of skill and understanding. And so, I mean, you stuck with her and, you know, it was probably due to your relationship. And she finally ended up saying, you know, yes, I trust him and I'm going to do it. I'm ready.

But it took a lot of time to get there. And I think, you know, part of the problem is that that is lacking in our current system. I mean, people have a 15-minute appointment with their PCP and walk out with a prescription. I mean, that's, you know, barely scratching the surface of anything. Yep. Yeah. And, you know, for 20 years in psychiatry, we've known that it's not just like a serotonin deficiency and you need more serotonin.

But that kind of stuck, you know? And so now people in the public are learning like, oh, that's not the case. It's a, and in my mind, it's like a lot more complicated. I did an episode on it. It's like really complicated, right? Very complicated. but speaks to the power of messaging and marketing. And that unfortunately has kind of overlapped and, you know,

certainly pervaded people's understanding of themselves, of mental health care, of treatment. I've had people walk into my office and sit down and say, well, I have a chemical imbalance. I mean, that's just how they define themselves. I call that a disease narrative. They believe. It's like the same thing if the person walks in and they're like, oh, I'm on bone on bone on my knee.

And so it's always going to be painful. It's like, no, you're probably not bone on bone. It's like. But when people will like have this narrative about themselves, it like propagates a stress response, right? Or they get more easily co-opted into a place of hopelessness. or they don't they're not able to find the root issue right which by definition will take time i mean the root it's buried yeah it's under the surface um you got to dig through some dirt some layers to get to the root and and that's just by definition and intuitively i think people grasp that and they

appreciate that, that there may be some things that they're doing and the reasons why are outside of their awareness. And I think they understand that. Of course, you know, they need to work with a therapist to help guide them through all of that. But I think people are, you know, for those people who are willing to go to therapy, like we said, half of our sample said so, you know, that's the kind of therapy that they're looking for. Okay, so there was one area in this survey that was kind of interesting. If you were to consider therapy, how would you go about doing so? 60% said they would ask their physician for recommendations highlighting the gatekeeping

role that physicians play. And so if that physician is very medication management-driven biological model, you know, they may not recommend therapy. Absolutely. Right. That's right. And we don't really, well, we know a few things. We know, right, that internists prescribe about 80% of the antidepressants in the country.

So they probably just treat many of these patients themselves without referring them to a psychiatrist or therapist. And, yeah, we also know they don't get a lot of detailed training on mental health. care and mental health issues in their medical training. So we don't really know how are physicians making these decisions to either give someone a script themselves, to refer them out to a psychiatrist or psychotherapist. And I would love to do a comparable set of research with MDs to further understand that referral process and how they think about making those kinds of decisions. because clearly the public is looking to their physician as the gatekeeper as kind of the first point to stop at. That was the top answer, the number one answer.

What would you do? They'd go to their doctor and ask them. We were really surprised by this because we thought, well, the number one answer is going to be people are just going to jump online and start Googling. And actually, that's at the bottom of the list. We were very surprised that for all age groups, even younger folks, they would go to the, their doctor first. Yeah. I think some doctors are the pipe pipers of partial and good therapy, and some are not, right? And there was a physician doctor pro. She's been on my podcast twice. She was on here for borderline personality disorder. She is so amazing at getting patients to actually

engage in care. And probably one of the most, just keeping the ball going with people. You know, like, yes, this is going to help. Keep going. And people would believe her, you know, and they would go to partial and they would get better. And that was, like, sometimes that was enough,

therapy-wise. So if you're a psychiatrist listening to this, it's like sometimes you just encouraging someone to engage treatment is enough. and pointing and pointing out like this is a dose response, right? The studies on dialectical behavioral therapy, transverse focus therapy, mentalization-based therapy, scheming focus therapy, it was all like a year long, right?

Like this is not short-term one month, you're done. This is like a journey, you know? Right. somehow it's it's like unless you've looked at those studies you could you could be under the impression that oh it's just as long as the insurance will allow us to do which is a month or two right right but if you think of it in terms of you know if this is something that you know a person has been struggling with for their entire lives you know perhaps like an early childhood experience of a trauma or something like that, you know, one year of therapy is actually not all that long. It's probably for that

person, sounds like a pretty good deal to do a year, you know, a year of therapy to kind of address something that's been plaguing them for decades. Right. If something, if you have attachment wounds, there's tens of thousands of moments of contact that led to that, right? It's not going to be an easy fix. It's just not. It's going to take enough treatment over a long period of time. Yeah, absolutely. So let me see. Another answer was, so how would you go about seeing a therapist? So 53% said they would look for mental health providers covered by their insurance, which is consistent with their concerns of the cost of therapy. So there were a lot of people who did have concerns of cost of therapy. That was the number one concern. Yeah. Number one concern and the number one barrier that

stops people from pursuing therapy is they're worried they can't afford it. It's too expensive. Yeah. You know, another part of this issue of cost and affordability, though, is really confusion about their insurance. In our sample, 96% of the insurance, you know, another sample, of the cost, of the people had health insurance, which again, a nationwide sample. So I guess we are, the ACA is having some impact there with most people now having a health insurance plan. But over a third of people said they had no idea whether mental health care was even covered by their plan or not. Okay. And so again, with the ACA, it should be covered. It's an essential benefit.

fit, just like your annual checkup or anything like that, and it should be covered. But people are still very confused about what is their plan cover, what does it not cover, how does it work? And so maybe also it's that confusion that stops them from getting the help they need or looking more further into it. Yeah, and I've had people say they go down their list of people that are covered and everyone's not receiving clients. Yeah, so, I mean, there's a lot, like, even if they are covered. Now, there's a rule if they are in the Obamacare grouping, the Affordable Care Act, that they should be able to get treatment within 10 days.

Of course, that doesn't happen. But there's a legal ramification for that. So legally, insurance has to get them the treatment necessary. a certain amount of time. They have to have people that are providers. There are ways to complain about this. Maybe I'll put it in my episode notes. Yeah. People have to know about that, that they can complain, that there are ways to complain, that they have rights here. Right. Okay, one third of respondents said they would ask their family or friends for referrals. I think that just shows, like, most people have some sort of stigma about this. They would almost not ask their families.

family or friends. Mm-hmm. Mm-hmm. Yeah, only 25% would search Google. Yeah, and again, you know, maybe today these numbers will, I would imagine, shift around a little bit. But, yeah, it also points to me to part of a broader issue, which is that people really don't know how to find a good therapist quickly, how to even assess a therapist if they're actually meeting with what to look for. And I think if you, you know, look at a lot of the guidance that's

out there in the popular press, it's, it's very focused on sort of, you know, sorting people by diagnosis, you know, anxiety, do this, you know, depression, do that, look for a therapist. And, you know, that's also counter to what a lot of the evidence has said for decades, which is, you know, the effective ingredient in therapy is the relationship between the client or patient and the therapist. That's what's curative. That's what's healing. That's what's going to help you, just like your colleague who finally got people to go into treatments because they trusted her. They had a relationship with her. And so I think, you know, if we could do anything, it would be to educate the public that you should be looking for someone you feel comfortable with,

that you can open up to, that you can trust, that you think is deeply listening to you, that you can have a really rich relationship with, that's what you should be looking for, more so than, you know, have you done, you know, protocols in treating people with GAD or something like that? Yeah, modality is not as important as your connection with your therapist as, you know, do you trust this individual? Do you feel connected with them? Do you feel like understood and heard? Does this person seem to respect you regardless of your mistakes? Exactly. Can you go to them and tell them they made a mistake?

Can you disagree with them? Can you point out frustrations? Or, you know, often as a psychiatrist, I'll have clients to say, I don't really want to go back to the therapist. I'm like, what happened? Then they tell me what happened. And I said, have you told the therapist this? they said no. And I'm like, maybe you should and see what happens. You know, I think, I know this person. I think they're competent and probably will not shame you the way that you think you may be shamed.

You know, I would say that if my patient has told me that they're fearing being shamed. Right. And lo and behold, they go back to the therapist and most times they're able to work it out. So part of longer term work is also taking the risk as a patient. to point out where you feel unheard, point out where you have a disagreement, point out where you feel upset. Absolutely. And those are often the moments that are the most powerful in therapy and that really can change

someone's life because they probably have lived their whole life, you know, fearing, oh, I can't say that to my parent because, you know, they'll shame me or punish me. And maybe that's exactly what they need to do to try that out. and they can do that with a good therapist. A good therapist will welcome those kinds of conversations. A good therapist wants to have those kinds of conversations and experiences with patients. And that's going back to something you said earlier. That's why, you know, when we see apps advertising, oh, you can switch your therapist at the drop of the hat.

If you want to get a new therapist, press this button. That's why that kind of a feature in these apps is, is so. awful because then the person that never gets the chance to experience probably the exact thing they need. Yeah, with the caveat that if they were going to stop altogether, it's probably better to see a second therapist than stop altogether. And I've had a number of patients who, for whatever reason, they see a first therapist and it didn't work out and I'm talking to them and then we're like, well, let's try someone

else and they try someone else and it's a good fit. And so I think like... No, absolutely. Absolutely. I mean, I think, you know, initially earlier on, you know, you meet with a few different therapists if you're lucky enough to be able to do that. And, you know, certainly pick the one that feels like the best fit for you. Absolutely. I'm not saying go to one therapist and you have to stick with them forever. I didn't do that. I went to several different therapists myself and said, I had a few sessions with that. No, this doesn't really feel. And then I guess I'm referring more to like what you. you were talking about if there's an impasse or, you know, the patient feels hurt or, you know, upset by something the therapist said and they're already well into, you know, their relationship, their treatment. Yeah. It's similar to advice. I was just talking to a guy friend and he's like, oh, you know, I need more time. I'm in this relationship, but she wants me to not do these things

that I want to do. I want to work. I want to go out with my guy friends. I'm like, I think you're going to have the same problem in a future relationship. Like, you're just going to work it out in this one or work it out in the next one, you know? And kind of looked at me like, oh, hmm, okay. You know, and it's, but it's like, yeah. Yeah, that is what my last girlfriend said too, huh? Yeah.

So I think it's the same with the therapist, you know, like you may run into the same problem twice or three times with three different therapists. and it's like, okay, well, why not just say out loud what you think the problem is, what's happened, what's happened in the past, what you feel like it's currently happening, and see what happens, you know, take a risk there. Yeah. Okay. How did people in this study compare psychoanalysis and CBT? Yeah, very interesting. Well, to start off, we gave them a list of a number of different kinds of therapy and different modalities and said, which ones do you recognize? And really, out of the entire list, the only ones that people recognized were psychoanalysis or psychoanalytic therapy and CBT, cognitive behavioral therapy.

People also checked off mindfulness-based therapy and humanistic therapy, but I really think that they check those off because they just are more common names and they probably have heard mindfulness in a number of different contexts or meditation, for example. But really the only two therapies that people were aware of were psychoanalytic and CBT. And I will just say for some of the clinicians out there listening, even the term psychodynamic, which I think many clinicians use, the public does not know that term at all. That's a word they've never heard of. So if you are out there saying you're a psychodynamic therapist, you're probably confusing a lot of people unnecessarily perhaps. But 16% of people knew what that was in the sample, 16% whereas 64% CBT, 66% psychoanalysis.

Right. 42% mindfulness-based therapy, 30% humanistic. So it's like, yeah, how you're describing yourself may be completely unknowable. And yeah. Yeah. And actually one of the qualitative interviews that I did with, with a woman early on, I asked her if she had heard of psychodynamic and she said, no, I've never heard that word before.

And I said, well, just what do you think it might be or what does it mean? What pops into your head when you think about that word? And she said, well, psycho, dynamic, movement, motion. Oh, maybe it's a dance therapy. I mean, so, you know, it's really interesting. I wonder if Shedler practices it that way, you know? I can seem doing some dance therapy with some clients. We'll have to ask him.

Is that part of his frame or not? I don't know. I'll have to ask him in a future episode. Yeah, yeah, yeah, yeah. We'll have to check that out with Jonathan. But yeah, it's very interesting, right? You know, what the public actually thinks about what we say and what we do. Yeah.

So most people really only know psychoanalysis and CBT. That's like... Right. Right. And generally, you know, a lot of their associations, of course, come from, you know, what they've read and, you know, of course, been exposed to, right? That's how they develop ideas about things. And, you know, they do associate psychoanalytic therapy with self-understanding and getting to the root of their problems. And it's very interesting because that's, you know, at the beginning of the survey, what we talked about, that's kind of the top. the main thing people want out of therapy. But, and people associate that with, oh, getting to the root, yeah, you would do that in a psychoanalytic therapy.

And CBT is mostly associated with, you know, changing behaviors, helping people get control over their lives and things like that, which people said, though, at the beginning of the survey, are not that important. It was not a top need of theirs to get control over their lives or changing. behaviors. They wanted a lot more out of therapy. But they did also think that CBT was more evidence-based and more updated, which is a perception. It's not the reality. And so I think for the psychoanalytic field, I think there's a big opportunity and a big need here for more education on the evidence-based that does underlie psychoanalytic therapy,

because it's there, it's a strong evidence base, but people don't know about it. Right, and I think that, you know, psychoanalytic therapy also means different things to different people, you know. Some are very attachment focused in psychodynamic therapy or psychoanalytic therapy, and, you know, they're really focused on the relationship,

what's going on in the room between the person and them, whereas some people are, you know, looking at more insight-oriented, you know, what's underneath everything. So even within psychoanalysis, it's like there are so many schools, so many different ways of approaching it. Right, right, which has probably, you know, contributed to some of the confusion and distortion that the public has about what actually is it. Yeah. Yeah. Yeah. Okay. So the framework, grounded in research, four key elements that we should make an effort to communicate with the general public about depth therapy. You want me to list them off? Yeah, go for it. Go for it. Okay. So the four key elements

here to feel heard, to have change and choice, it's worth it. There's an emotional benefit and getting to the root of things rather than superficial. Yeah, we tried to, yeah, sort of, you know, bubble up and all the data and the findings, you know, and kind of consolidate them into a framework. You know, what do people really want from therapy and, you know, how can we communicate the benefits of a therapy of depth insight and relationship to the public and sort of build that bridge between what therapists can offer and what the public wants. And so we put it into this framework. And of course, you know, if someone goes to therapy, of course, at a minimum, at a bare minimum, they need to feel heard and feel safe and feel okay sharing with the therapist without feeling embarrassed or

shamed or judged. And, you know, just at a rational level, what do they want to get out of therapy? Well, they want to change parts of their lives and they want to have more choice to have different feelings, different relationships, different thoughts, kind of more emotional. level, there was the concept of that therapy is worth it. Therapy is worth investing in and going through that process and also you're worth it. So you're worth having this experience of transformation and understanding. And then really the most differentiating factor that really only a therapy of depth insight and relationship can provide is really that benefit of helping people get to the root of their issues in themselves. Right. And, you know, interestingly, when I was looking at some

other studies on, like, what actually happens in therapy, right? And CBT, like effective CBT, a lot of these things are right there as well, right? It's that there's a focus on the relationship, focus on emotions, focus on getting the root of things. So I think in any effective therapy, these things are going on, we just call it different things and we have different words to describe things often, you know, but that being said, like I would say a good therapist knows how to navigate a prolonged relationship and the, you know, emotions that come up in the midst of it, the countertransference, how to navigate interpersonal conflicts better maybe than the average therapist. Like that's like what I would say. There's some good studies to promote. So I think all therapy has these elements when it's

effective and it's a good it's a good reminder that we need to continue to focus on these things that patients care about these things right yeah absolutely these are the top things for patients and also right as you said for good therapists and I think probably you know once you get inside the consulting room good therapists are doing you know many of the same things maybe having different terms or terminology for it I agree you know I think where the distance connect is, is the public doesn't know that. And the public is bombarded with, you know, CBT and apps and, you know, this is what they're hearing out there. And as a result, you know, very confused and not really knowing, how should I pick a therapist? What should I look for?

What should I be trying to find here? And so I'm really hoping that with a lot of our efforts, we can help educate people so they can become more informed when they're making important health care decisions. Okay. Yeah. So what are some of the future, like, directions that your organization is going to take to sort of make some of these changes? Like, what do you hope for in the future?

Well, we are working on a large effort to educate the public because we heard through this research over and over again that, that, People are also just confused and don't really know where to go for help and what it's called and how to find it and how to trust it. So we are trying to educate the public and building a new website and tools directed for the public. Up until now, we've been mainly focused on professional audiences ourselves. I also, you know, had mentioned we'd love to do comparable research with different audiences with those gatekeeper physicians, for example, with therapists and academics teaching the therapists of tomorrow. We're, you know, continuing to be concerned about, you know,

advertising messages that are just creating confusion for the public. And so we've undergone a few successful initiatives where we've pushed back with the FTC and other. organizations and to help protect the public from misleading marketing messages. And so I'm sure we'll be doing a lot more of that going forward as well in addition to the summer building on this research and refreshing it. Excellent. Great. Yeah. Any other sort of things you wanted to mention before we sort of wrap up our time here today? No, I just thank you for making this space available and for your supportive therapy, I think it's, you know, can be an incredibly effective and powerful experience. And, you know, I just want to help demystify it for people.

And I think, you know, your podcast is one way to do that. And I hope, you know, to get more of the messages out there because, you know, there are a lot of people suffering out there. And when you're suffering, you're vulnerable. And it's hard to know what to do or whom to trust. And I just hope that, you know, a lot of us working together can can just help inform people better. So they feel more confident in taking care of themselves. I appreciate your support. And I think it's fun to find people that are doing, they're running in the same lane, maybe slightly apart from each other, thinking about the same goals. You know, my goal in starting the podcast was if I could get 10,000 professionals.

to do better therapy, better psychiatric care. I thought I could reach enough people to make it worthwhile. And I think we have surpass that. And so it's been a good journey. And I think what I'm hoping for in the future, though, is we can actually make, you know, like national wide changes to move towards directions that are in the best interest of patients.

And how we're going to do that is together, right? I mean, there's no other way that we can do something like that, but we need to work together collectively. Yeah, yeah, there is no other way. And that's why at Psychotherapy Action Network, we deliberately from the beginning set out a very big tent. And we have psychiatrists, psychologists, social workers, counselors, marriage and family. I mean, everyone under the tent and people who practice with very different theoretical orientations and have very different training. but what unites a lot of our members is, you know, a desire to do good work and to help people and to counter a lot of, you know, we certainly don't have the marketing budget that pharmaceutical companies have. We never will, but we know what works and we want to share that information with people. And so, you know, that's part of our, the reason we publish that

book, which I hope people check out. And there's a lot more info on our website, of course. But yeah, it would be great for all of us running in same or similar lanes to come together because we have, we got into this to help people. Yes, to make a living for ourselves, but we're, we want to help people. And we have a lot of knowledge and a lot of data and experience about how to do that really well. Yep. Simple things you can do. Share the episode with a friend, colleague, you know, join us on Twitter, Instagram, share stories, share tweets, you know, retweet, little things like that, like make a big impact. Like we are going against huge budgets, like literally billion dollar budgets.

Like I have no way of beating a billion dollar budget, but by colleagues sharing with other colleagues. And I really think that's more trustworthy. I think what I've heard for most of my listeners is they got the recommendation of this podcast from a colleague that trusted it, that listened to it, enough to realize that I was, you know, trying to stick to the evidence. maybe thinking outside the box in some areas, but in an evidence-based way. And so, you know, share with your colleagues, you know, the problems that we face and

hopefully we can work together as a collective to make some changes. But it's going to take some networking, some synergy. And so we will be hopefully having you back in the future to get updates on what's going on. and we'll leave it there for today. Sounds great. Thanks so much.