Talk therapy is an opaque good, and most providers are bad at it

I have seen a handful of therapists in my life. Most (~75%) were ineffective and added to confusion, shame, and financial stress by virtue of being expensive. A few were neutral and forgettable. The most helpful one was deeply empathetic - the kind of friend that you'd love to have in your corner.

When buying mental health services, the friction of starting and shopping around is high. Depression or anxiety makes it less likely that you'll even try. Every encounter with a gating staff member (primary care, insurance providers, receptionists, triage nurses) is an opportunity for someone's unintentional lack of care to wear you down and bring the process to a halt. The first and only time I ever approached my family doctor about depression and self-harm, she told me I was overreacting and did no followup. The entire appointment took 10 minutes and she charged a healthy sum for it anyway. I proceeded to find a local therapist on Google who ate up the insurance budget for the year, and gave me CBT worksheets (copyrighted under her name) printed in Comic Sans with children's cartoons. The entire experience was benignly useless. I gave up for a number of years after that and continued self-harming. I have heard similar private anecdotes of incompetence and disappointment from friends. The internet is also not short of examples.

From my small survey, I've come to the unscientific conclusion that the majority of professionals who deal with mental health are not very good at what they do. Neither credentials, decades of experience, nor employment at a well-regarded practice seem to be reliable predictors of fit or competence. There are diamonds out there, but I have no idea how to find them except through sheer luck.

Imagine trying to rent a car in the following scenario: brands are meaningless - a Lexus is as likely to be a lemon as a Lada. There are no refunds. There is no customer support line if the seats are dirty. There are no reviews. The whole thing is manufactured in an unknown factory through an unknown process. You can’t test drive it. You don’t even know what car you’re going to get when you book. You have to pay and just show up. If the car doesn’t work, tough luck for you. You can pay to try driving it again though.

This is insanity. It doesn’t take an economist to tell you that such a market is broken.

This isn't surprising. Therapy is an opaque good: unlike Yelp or UberEats, there is no public record of experience. You can't even call for references; no therapist is allowed to disclose the contact info of a current patient to a prospective buyer. Often, the choice of therapist isn't even made by the patient - it's made by the referring physician, the insurance company, or the triaging staff member. Add the fact that credentials tend to beget credentials, and it's no surprise that the modern psychotherapy market is a place where a mediocre therapist can build a career and collect stellar credentials despite being quite poor at what they do.

I have also been lucky to experience the impressive benefits of an effective therapist, which is why I haven't given up wholesale on the field of psychology. I largely steer clear of the self-help genre: it's annoying woo-woo and self-promotional. But psychology books - particularly the ones aimed at practitioners, with a strong scientific basis - can produce valuable insight when combined with introspection. I now try to research and produce mental health progress for myself, and I’ll be using this blog as a record of sorts.

I may be an amateur, but the mental health marketplace is an opaque dartboard which sets the average buyer up for disappointment. I have lost interest in throwing expensive darts out into the dark.

Outsourcing mental health has not brought returns for me, so I'm giving it a go in-house. Let's see what happens.