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Are Online Reviews Dumbing Down Psychotherapy?

2015Psyched in San Francisco Yelp and Online Reviews for Psychotherapy from SF Chronicle

Photo Credits San Francisco Chronicle

Authors: Psyched in San Francisco’s Andrew GroeschelDietmar Brinkmann, Lily Sloane, Dr. Robert Solley and Traci Ruble

Psychotherapy is an interesting business because sometimes successful therapy requires discomfort which can look like bad customer service at certain points in the treatment. For instance, sometimes clients get angry at their therapists as an important part of the healing. So how can we decipher good therapy from bad therapy when therapy is sometimes a messy process? In the middle of these reactivities, psychotherapists are bound by a strict ethics code that is increasingly being dismissed by many therapists whose need to earn a living requires that they generate many clients quickly in a saturated Bay Area marketplace.  And some consumers have told us they are happy therapists are “breaking their ethics rules” because they feel online reviews simplify their search for a therapist.  The story got so hot it was on the front page of the SF Chronicle’s Business Section this weekend.

As I grew my successful individual psychotherapy practice to a psychotherapy group with twelve therapists, colleagues made the case that therapists’ governing bodies are woefully behind in thinking through technology and marketing issues and soliciting clients for online reviews should be a mainstay of my marketing strategy despite the ethics code that prohibits this. I tried going the online review route but it just didn’t mesh with how I work so I cancelled our paid advertising on online review sites (with a hefty fee). How does a therapist’s good work speak for itself if an ethical consumer forum doesn’t exist? It’s quite a conundrum.

The clinicians here at Psyched had a long series of conversations and email exchanges as we got really curious about online reviews – pro and con.  Many of us here at our clinic crafted this article together and even those who did not co-author shared their thoughts. We want you to think critically right along with us by adding your nuanced thinking to the conversation. I ask one thing if you comment: be curious and respectful of all other commenters’ points of view.

Our deepest intention here at Psyched in San Francisco in forwarding this discussion is to:

  1. Empower consumers to choose wisely. Are therapists with the most reviews the best or simply the best at using review sites as part of their marketing strategy? What are the best places to locate a therapist? How should one go about the process? When can a consumer tell if the therapy they are receiving is effective therapy?

  2. Inspire high-quality mental health care. If therapy is often about being confronted by things inside of ourselves that “suck” to look at, what happens to the quality of the therapy when therapists stop the skillful confronting and replace it with “woo woo” and “happy pappy” ego stroking for fear of a bad review? What are therapists to do to maintain a level playing field of high efficacy therapy across a large landscape of many different styles of working toward change and many different styles of marketing?

  3. Model open discussion, activism and professional empowerment by therapists that isn’t mired in the status quo but thoughtful about the realities of modern technology.  We can’t rely on our governing bodies to dictate the rules without being a part of the dialogue in a thoughtful, caring and empowered way. Therapy and therapists have changed along with technology and leaving the discussion up to a governing body who may be more removed from the realities of this work isn’t embodying healthy individuation and interdependence.

What is so special about therapy compared to my local burger joint? You should be accountable to the public like everyone else.

While different models of therapy (aka Theories of Change) hold the relationship between client and therapist in different regards, many therapists believe this relationship is an essential part of how therapy works. And while there are boundaries (limits of professional behavior and a strict code of conduct)  in place which we don’t usually have to uphold in relationships with friends, family, and lovers, therapy requires a level of openness from the client and authenticity from the therapist that just doesn’t jive with a “customer satisfaction” model. And not because we’re jerks and we want to get away with it, but because healing and growing doesn’t necessarily mean doing what’s easy or comfortable.

Many therapists would agree the emotional wounds we bring into therapy are relational wounds (from early caregivers, from love, loss, and disappointment). Humans are social creatures who not only crave, but require connection at our very core, so to heal these relational wounds we need a healing relationship. This process can be challenging. You may get mad at your therapist and, unlike your waiter at a restaurant, the therapist’s job isn’t to make you happy with your order – it’s to help you heal and grow.

Dr. Robert Solley points out some distinct differences between the therapeutic relationship and other professional relations in this table.

Therapy Relationship

Other Prof. Relationships


Mostly not private – obvious exceptions: lawyer, doctor

Most are deeply personal, vulnerable

To some extent with doctor, but all other professional relationships are not as personally vulnerable.

Object of study and source of change involves the very relationship itself.

The relationship is part of a larger service but not the service itself in the same way.

Your therapist may serve as a stand in for your mother or father and you are invited to act that out to resolve old patterns from these relationships.

May believe your mechanic is like your father but that transfer is not intended to be used to heal some old emotional dynamic.

Therapist in relative position of power over client because of imbalance in emotional vulnerability, helper vs. helpee.

Not in the same position of power to the same degree.

How is our therapy culture changing?

To provide some historical context: In his book, Secrets of the Soul: A Social and Cultural History of Psychoanalysis, Eli Zaretsky’s teaches us that the “talking cure” came about at the very point pre-industrial social structures, church confessional and family roles and rules were being eroded by the advent of the industrial revolution and early capitalism’s increased focus on individuality. Freudian psychotherapy came about as Victorian family structure was being surpassed by the ability of individuals to construct extra-familial identities. “As a result personal identity became a problem for individuals to grapple with as their roles were no longer dictated by their family or their church…” Zaretsky argues that to Freud “There was no necessary or direct connection between private and public life.”

While clinicians practice in many different ways, even classical psychoanalytic therapy has evolved over time. The context in which we live now includes a world of technology, globalization, and convenience. While social-media and tech-immersion and the world of online reviews is part of the air-supply for 20-30 somethings there is a dilemma of how to bring them from the world of screens back into the world of relating in the flesh. Arguable, people and relationships are more complex than cars, movies, and restaurants. Therapists now grapple with, downright reject, or fully embrace this question of how to begin a therapeutic relationship in a non relational way (online) where the screen’s appeal is it’s relative lack of complexity and complication.

Additionally, psychotherapists these days are a unique and sometimes precarious hybrid between being a healer and a commonplace provider of healthcare. Therapists in private practice are also business owners, who need to promote themselves and their services.

There is a shift from finding a therapist by referral from doctors and trusted friends to online shopping for therapy services. Business coach Lynn Grodzki says that more than 50% of new clients find their therapist online. (Psychotherapy Networker, Sept/Oct 2013) The internet has made us all into well educated consumers. We compare, contrast and learn as we go. Because of the consumers expectations that businesses will be listed on review sites, how many talented clinicians are never considered because potential clients don’t know how to find them?

There are some interesting and large shifts in the therapy marketplace. The first is there are more therapists than there ever used to be and in the Bay we are saturated. The second trend is traditional relational therapy is being replaced by more forms of “behavior modification” type therapy. So the therapy for many, that is being sought out, is non relational therapy via a non relational means. Finally it is fascinating that while the early therapists were mostly men, increasingly therapy is a field of women. How do gender inequality, financial strain in a saturated marketplace, mental health stigma, and wildly varying views on how change happens impact our need to increase our worth via the online reviews marketplace?

Online Reviewing of Therapists Has Some Really Good Stuff

Online reviews and social media, more generally, have the unique impact of making the personal profoundly public once again.  The generational ramifications of this shift toward having much of one’s life available on-line has shifted the pendulum back in an odd, post-modern way in which public and private have been conflated in some ways. Like anything, there are pros and cons. Here are a few of the ways we see this shift potentially benefitting the consumer:

1. Online reviews can create more access when you don’t personally know someone who can give you a referral. Looking for a therapist can be tough. I think most people would agree that what they are looking for in a therapist is emotional safety and a strong interpersonal connection. Obviously the best way to find out about the interpersonal style of a therapist is asking someone who knows this therapist. But what do you do when there is no local friend or trusted health professional to ask for a recommendation? Reading about others’ experiences may help you feel more comfortable giving a stranger a shot.

2. Online reviews could potentially hold therapists accountable to unethical practices. Because of the confidential nature of psychotherapy, the vast array of modalities, and the subjectivity of the work, it can be difficult to determine if a therapist is competent and ethical in their work. Online reviews could potentially provide oversight from the public and with enough reviews leaning in a particular direction it might be enough to dissuade someone from selecting a “bad” therapist. (Though in the current state of therapist reviews this isn’t a reliable source of such information.)

3. Online reviews can help de-stigmatize therapy. It’s exciting to think that those who have benefited from therapy would be willing to out themselves publicly and say “Hey I needed help, I got it and it worked.”  Online reviews can help to reduce stigma around help-seeking and help regular people understand what therapy is all about. It may help them to seek out effective support that could radically alter the course of their life.

What are the drawbacks to online reviews?

1. Online reviews break the consumer’s confidentiality. Clients who choose to leave a review for their therapist break their own confidentiality in doing so. Because of mental health stigma, this could potentially lead to discrimination (“ahh I see you have sought out psychotherapy? Can you tell us more about any mental issues you may have had in the past that may impact your job performance should we hire you?”).

2. Because of rules surrounding confidentiality, therapists have little recourse when faced negative reviews. If a costumer at a restaurant has a terrible experience and leaves a negative review, the restaurant’s manager can respond to the review with an explanation, apology, or retort. However, a therapist can not do this. Even though the client has already outed his or herself as a client, the therapist is in no way allowed to acknowledge that they treated this person. Even leaving a general response is pretty iffy. Many therapists would feel uncomfortable engaging a client in this discussion in a public forum and it could further damage the ruptured relationship.

2. Online reviews don’t account for the long-term complex relationship that is inherent in many therapies and the sensitive nature of therapy. Being in therapy often includes talking about difficult and potentially embarrassing topics. Most of the time the experience is incredibly freeing, but it can also leave the client feeling very vulnerable and wondering if it is safe to open up. Good therapy makes room to discuss these feelings and concerns. But even with the best precautions and genuine openness of the therapist, clients sometimes stay quiet about their concerns and make up stories about the therapist and about what happened. This can lead to complications in the relationship and even to a client ending therapy prematurely without an opportunity for client and therapist to hash out what came up between them.

3. Therapy is a very individual process, so “rave” reviews could set unrealistic expectations for potential clients. Too high expectations and ambitious goals can be a setup for the client and the therapist.  Online reviews for psychotherapists can create a parallel effect as Facebook has on life in general: Because Facebook posts are heavily skewed towards positive and extraordinary experiences, it can make regular, day-to-day life seem dull and insignificant. Similarly, reading rave reviews about a therapist may shape expectations towards fast and easy change: “The online reviewers had such an amazing break-thru in therapy. Why am I struggling so much? This shouldn’t be hard. This shouldn’t take so long.” We go to therapy for so many different reasons and there is no one-size-fits-all therapy.

4. Online reviews may consciously or unconsciously shift the way therapists work. There is some concern that therapists are becoming more anxious about taking on challenging cases out of fear of setting themselves up to deal with an angry, perhaps retaliatory client. Would we refer out a client with emotional volatility to protect the online profile? Will clients with anger issues be able to find a therapist? In certain situations (court ordered clients, co-parenting agreements, couples in conflict to name a few) it can be of essential therapeutic value for the therapist to hold up clear boundaries. That can bring up a lot of frustration in clients. Therapist may become hesitant to stand their ground for fear of a damaging online review from a disgruntled client. However, this choice may be damaging to the client or at least not helpful in their healing process.

5. Clients may feel pressured to give a positive review. Therapy ideally includes authenticity, openness, and vulnerability. But because the therapist is in the “expert” position, there is a power differential in the relationship. Some clients will rage against the machine and bump up against the therapist’s authority as part of their growth process. However, many others may idealize or aim to please their therapist. If solicited for an online review, such a pleasing client may comply but at the detriment to his or her own self and at detriment to the treatment.

The Data and The Rules

Psyched in SF Psychotherapy online reviews and YelpIn our informal poll of Bay Area therapists, a staggering percentage are not listed on online review sites. Those who had seven or more reviews were shown to be more likely to engage in strategies to gain more reviews as part of their marketing. Therapists, overwhelmingly, were concerned about online reviews as a marketing practice because of its negative effect on therapy. Conversely, while all therapists in the state of California are bound to an ethics code about online reviews, it seems many are willing to break this code. Some therapists in the polling expressed concern that if these clinicians were willing to break this ethical commitment, what other ethical violations might they be committing. Others said they didn’t believe so many patients would out such a private thing on a website so felt many of the reviews were bogus. Yet it can’t be denied that therapists who are choosing to overlook the state’s code of ethics and cultivate a large online review profile have thriving practices and the therapists who are adhering to the state ethics code will continue to have their practices penalized through lower revenue.

What is the solution?

We’d like to hear from you. We’ve decided to put a disclaimer on our Yelp page. We do share reviews from web on our site with a disclaimer and some criticize us for this. It’s our best “walking the middle line” that we could come up with. We have collectively decided not to ask clients or colleagues for reviews.  Our training and the sheer breadth and depth of our team should speak for itself.  Most of our referrals right now come from previous clients and other therapists or health care providers. Fewer of our cases come from the internet because we don’t advertise on online review sites.

In our consumer poll, most people seeking treatment relied on a trusted friend for a referral to a therapist, not online reviews. That bodes well for us as at Psyched as many of our clients refer back to our center. In the meantime, all therapists are left to grapple with the reality of this review question. Most get black and white on the issue, adhering to old norms and rules developed over a century ago.  We challenge everyone to think through this with an open mind and for consumers to turn to someone they trust (a friend, doctor, teacher) to get names of therapists. It’s a good idea to call them up and talk to several so you can get a feel for how they work. The therapy relationship is really important so respect yourself and your growth by finding a fit you like. There is a great referral site called www.goodtherapy.org. Good Therapy does a great job educating consumers on different types of therapy so you can hone in on what you are looking for. Check them out.

If you’re a consumer and would like a consumer guide for finding a therapist, we have one in the works.  Add your email to this list and we’ll send it to you once it’s ready. Or call us. Our hope is to become the reputable source for people in San Francisco looking for therapy. Even if we aren’t a match we like helping match people with the right therapist and refer out to esteemed therapists and colleagues we trust.