Even for people who have the time and money to choose, it’s hard to know what to look for. In the absence of a referral or personal recommendation, many people turn to “Find a Therapist” databases from their insurance, ZocDoc, or Psychology Today. But current systems are, understandably, designed to prioritize things like cost, proximity, and availability of services—not expertise in a particular problem or a good fit between patient and provider.
Consider a person who is seeking help for time-consuming rituals. They are likely to end up talking to the next-available therapist about more obvious issues, like the depression or anxiety their rituals cause. Even if this person has a hunch that a label like OCD might apply, and searches for the condition by “issue” for OCD on the Psychology Today site, they will receive dozens of results for therapists who have tagged OCD on their provider pages but don’t actually employ the gold-standard treatment, exposure response prevention. To find a provider with expertise in ERP, the client would have to know what condition they have and what intervention they require, then deliberately search for providers by “type” of therapy offered instead. Even then, they may find that the therapist they’re paired with has all the right training but is untrustworthy, unprofessional, or unlikable.
When time is segmented into 50-minute billable increments, clients can’t afford to waste a second. But building an alliance with a therapist—or failing to do so—is often slow going. Some individuals seem supremely skilled at this work: In a 2003 study, psychologist John Okiishi found that, in a sample of 91 therapists, the top performers enabled their clients to improve 10 times faster than everyone else. But even a supershrink would, inevitably, struggle to help certain people.
When a client isn’t making progress, the therapist should be the one to point out the problems and offer a back-up plan. In situations where the alliance cannot be repaired (or never formed in the first place), a therapist will typically refer their client out to a colleague who might be a better fit. But in the US, financial incentives can get in the way. Kottler says therapists may be loath to let a source of revenue walk out the door; after all, their malpractice insurance, rent, and other payments are due. “There have been times in my life, honestly, when my income stream has gone down, and I really need to keep clients and I’m not getting many new referrals,” Kottler says. “And I won’t easily let a client go.”
Often, that leaves clients in the position of calling the whole thing off. Some end up ghosting. Others tell their therapist that they’re doing better even when they aren’t. Rare is the client who’s able to speak the truth: “You just aren’t helping me.”
Eliminating bad therapy entirely, whether in person or online, is a quixotic goal. But improvement starts with freeing both clients and therapists from getting trapped in the current “first come, first serve” model.