The hidden reason why therapy isn’t working

If we want to solve the mental health crisis in this country, we don’t just need more therapy. We need more good therapy.

As the CEO of a mental health therapy company that treats thousands of patients, I’ve seen how if we do a better job matching patients with the right therapists and measuring the effectiveness of therapy, we’ll get a lot closer to providing therapy that works.

In 2022, 55.8 million adults in the United States received treatment or counseling for their mental health, up from 41.7 million in 2021. And yet, our collective mental health is getting worse. There are plenty of potential factors at play here, but I find myself asking: With all our increased awareness of and investment in therapy to solve the mental health crisis, why hasn’t it had more of an impact?

Therapy effectiveness

It comes down to the effectiveness of therapy, not just access to it. But how can you tell the difference between good therapy and bad therapy?

I began exploring this question more than eight years ago, when my partner ended up in therapy with a clinician who wasn’t right for her. That therapist wasn’t providing the help she needed, and she didn’t know where to turn. She had simply been told that therapy was the answer.

Even as therapy has become less stigmatized, the issue of therapist quality remains in the shadows. For a long time, there was no real way for patients to be vocal about their experiences with bad therapists. It’s not easy to admit when therapy is a waste of time, and there’s been a lack of channels and forums for patients to communicate with each other.

But the conversation is starting to change in pockets of the internet, which I view as a sign of progress.

Finding the right therapist is nuanced

BetterHelp patients have been taking to TikTok to describe their negative experiences using the hashtag #betterhelptherapyisascam, viewed 1.4 million times. Buzzfeed compiled stories about the worst things therapists have done according to patients, from imposing their religious views to multitasking during sessions. There’s even an entire podcast dedicated to clients unpacking their experiences with “very bad therapy.”

These aren’t just one-off anecdotes. Evidence backs up that much of the therapy we’re getting today actually isn’t all that helpful. Last year, one of the largest mental health reports in U.S. history, including outcomes from 200,000 patients, showed that about 80% of patients do not experience “any clinically meaningful response to therapy”—not to mention those who experience lasting negative effects from bad therapy.

Despite what the proliferation of online therapy marketplaces would lead you to believe, finding the right therapist is more nuanced than simply selecting based on gender identity or ZIP code. There is a wide assortment of therapy treatments and practices, theoretical orientations and styles, all of which matter in finding the right therapist for your specific needs—and getting that relationship right is one of the most important factors in benefiting from therapy. Given the mismatch in how most therapy platforms are built and what actually makes a therapeutic relationship successful, it’s no surprise then that only 36% of patients make it to a fourth session before dropping out.

Even if you do find a therapist who feels like a good fit, there’s often no way to know if you’re actually getting better. In fact, less than 20% of mental health providers use measurement to inform their care, and even fewer share that data back with their patients. The lack of measurement and outcome orientation would not be acceptable in any other healthcare specialty.

Good therapy has an endpoint

So, how can you actually know if you’re matched with the right therapist? If you’re with the right therapist, you should feel—and see—the progress in your outcomes on measures like the PHQ9 for anxiety and GAD7 for depression. Good therapy should also have an end point. Once you’ve reached your goals for therapy, your therapist should empower you to take charge of your own mental health—not keep you tied to weekly sessions for years.

But measuring and improving individual patient outcomes isn’t enough. Without industry-wide standards for therapist competence and quality, we don’t have a consistent way to understand therapist performance and train more therapists to deliver upon those outcomes.

That’s why I, for one, am ready to start talking about the effectiveness of therapy. I started my company because of my partner’s bad experience, and I’ve been committed to solving this problem ever since.

Over time, we will need more therapists to meet the demand for mental healthcare. But in the immediate term, the most important thing we can do for patients is to raise quality standards of care. I am all for de-stigmatizing therapy, but we also need to recognize that not all behavioral health interventions are created equal. Given the mental health crisis we face in this country, it’s time to insist on a higher standard for the most efficacious tool we have in outpatient mental health.

Alex Katz, cofounder and CEO at Two Chairs.