Finding a Therapist
Many Americans struggle with mental health, yet the process of searching for a therapist is particularly challenging, especially for individuals that are in a desperate mental state. This report includes research methods, findings, and implications for design of a technology-based solution for finding a therapist.
Role: Experience Researcher
Year: 2020
In 2018, almost 14% of U.S. adults between 18 and 25 reported that they had a major depressive episode within the past year (Statista, n.d.) making it increasingly important for clients to be able to find an appropriate mental health professional (i.e., therapist) that fits their needs (Statista, n.d.). Choosing an appropriate therapist is critical in building a strong therapeutic alliance, which is perceived to have successful psychotherapeutic outcomes (Stamoulos et al., 2016). The strength of a therapeutic alliance is also heavily influenced by client personality characteristics and expectations of outcomes (Palmer, 2020). In this study, we will examine how a technology-based product might help people find a match with an appropriate therapist based on characteristics that build a strong alliance.
The factors that help to build strong therapeutic alliances between therapists and patients are called common factors, which can be defined as variables that are common across psychotherapeutic modalities that are unspecific to particular theories or techniques as defined by these unique modalities (Stamoulos et al., 2016). Some examples include alliance, empathy, warmth and congruence (Lambert & Barley, 2001). These factors have been shown to correlate more highly with client outcome than specialized treatment interventions (Lambert & Barley, 2001).
Market Scan
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Psychology Today Therapist Directory
The Psychology Today Therapist Directory is a list of licensed therapists and counselors that allow visitors to apply filters, such as location and specialty. The directory includes biographies for each provider, but there is no obvious indicator for treatment style or client fit. Additionally, users can only search by insurance provider, not by individual plan. The website also lacks scheduling capabilities.
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BetterHelp
Betterhelp uses the Depressive Experiences Questionnaire (DEQ) to match potential patients to a therapist that may fit their needs. However, the website does not share biographies of providers and the service is not covered by insurance. Patients are forced to pay out of pocket, even if they have health insurance that covers treatment with an in-network therapist.
How can a technology-based product help clients choose an appropriate therapist for their needs?
Research Question
Research Methods
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We recruited participants for the observation and interview phase in two ways: (1) CDM/COMM Participant Pool for Research and (2) our personal networks. For the survey phase, we recruited participants with (1) CDM/COMM Participant Pool for Research and (2) distributed the survey link via our social networks and our personal networks. For both the observation and interview phases, we observed eight participants through Zoom meetings where they verbally consented to an informed consent.
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A total of 34 participants completed the survey, of which 3 results were discarded, as they did not meet the survey participation criteria of having previously seen a therapist.
We analyzed responses from 31 participants, with a median age of 30-39. Of the respondents, 42% were between the ages of 20-29. 74.2% of participants were female, 19.4% were male, 6.5% selected “Other” or “Prefer not to say”.
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We began the observation and interview with an introduction and each participant verbally consented to an Informed Consent to be audio and video recorded.
During the observation phase, we asked participants to list three qualities they looked for when choosing a healthcare provider (“therapist”). We then explained our scenario-based observation activity. We asked participants to demonstrate how they would search for a mental healthcare professional online. The participants shared their screens so we could observe the activities they performed to complete the tasks. We recorded their actions and we took notes. After completing the observation activity, we asked participants to stop sharing their screens and wrapped up with questions about their observation experience. We asked participants to share what they found challenging about finding a mental healthcare provider. We also asked if they would have done anything differently if observed in person. Observations lasted for 30-50 minutes.
During the interview phase, we conducted eight remote interviews (through video-call) lasting 40-60 minutes. Each participant was briefed on the purpose of the interview and verbally consented to be audio and video recorded. Participants were then recorded while being asked questions about how they searched for a therapist, how they evaluated and selected therapists, and their challenges throughout the process. After participants completed the interviews, we asked follow-up and demographic questions, and asked if they had any questions for us.
For the survey phase, we used Qualtrics to develop and host our survey. We collected 34 responses between May 29, 2020 and June 1, 2020. Participants must have previously attended at least one therapy session. Participants answered a series of questions focused on search methods, selection criteria, and challenges. The survey ended with participants providing demographic information such as age, gender, and household income.
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During the observation phase, we utilized the contextual inquiry framework to sort our findings and identified how the participants completed the tasks. Additionally, we prepared an affinity diagram using Stormboard to identify the common patterns participants used to research and compare therapists.
For the interview phase, we transcribed all interviews and individually placed the transcripts into an Atlas.ti project. We then inductively coded the transcripts and created an affinity diagram using Stormboard to identify the similarities between the codes. We then created spectrums representing the most pervasive themes to identify key personas.
For the survey phase, we used Excel and R Studio to analyze the survey data. We reviewed a specific question to rate whether the participant was searching for a therapist for treatment of a psychological disorder, defined as any ongoing mental health issue such as stress, anxiety, and depression or if the participant was seeking help due to a specific life event such as grief and relationship troubles. If the response did not fit either category, it was rated as “Other”.
Based on our observation and interview data, we formulated two hypotheses:
Hypothesis 1: Importance of Insurance
Participants with insurance find it more important that a therapist is covered by insurance than those without insurance.
Hypothesis 2: Finding a therapist is always hard
There is no difference in perceived difficulty of finding a therapist between participants seeking treatment for psychological disorders versus assistance through a life event.
Finding a therapist can be a diffcult process
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Multiple sources to search
The majority (6 of 8) of interviewees said they referenced multiple sources during their search for a therapist. These included insurance provider websites, therapy focused websites, referrals from doctors and personal recommendations.
They said that information was fragmented between sources and was time consuming to sort through and evaluate, especially when they were starting the process of finding a therapist for the first time.
Maria mentioned that there was not a single source that provided all the information she needed to choose a therapist: “The deep dark black hole of searching for a healthcare provider on the internet...a hodgepodge combination of Google maps, Google reviews, attempting to navigate my insurance provider’s healthcare portal”.
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Personal references & reviews seem to help
63% (5 of 8) of observation participants said they preferred a reference to a therapist from someone they knew. Celeste looked for therapists that were affiliated with familiar hospital networks or practitioners. Interview and survey participants also mentioned that they relied on guidance from personal contacts, doctor recommendations, and patient reviews to narrow their search for a therapist.
Half of interviewees (4 of 8) made appointments with therapists they discovered through friends, coworkers and acquaintances. 50% (4 of 8) visited therapists based on referrals from a healthcare provider. Half of interviewees (4 of 8) looked for patient reviews on therapists.
The survey identified the tools that were most beneficial to participants in their search for a therapist. A 5-point Likert scale (1=Not at all helpful, 5=Very helpful) was used to gauge the usefulness of specific tools in participants’ search for a therapist. 52% of respondents indicated that referrals from friends, family and doctors were helpful. Respondents indicated that referrals from family and friends were very helpful (8 of 31) and helpful (2 of 31), and 6 of 31 indicated that doctor referrals were very helpful.
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Internet search: Google still rules but isn't very helpful
Observation and interview participants conducted their internet search for a therapist in diverse ways. 63% (5 of 8) of observation participants searched for a therapist by location. Two observation participants searched for information on how to find a therapist. Alyson utilized her insurance provider’s website to look for a therapist. All eight observation participants and 63% (5 of 8) of interviewees used Google searches to learn more about therapy types and specific therapists. Three of eight interviewees visited Psychology.com and PsychologyToday.com for information. Maria and Lisa mentioned referencing an online therapist directory from these websites. Survey results indicated that just 13% of survey participants found Google searches very helpful (3 of 31) or helpful (1 of 31).
User Criteria for Therapist Selection
Interview and survey participants searched for a therapist for different reasons and had a unique set of characteristics and qualifications when making their selection. Insurance plans and costs, location, availability, specialties, experience and shared connections were important factors.
Participants used a variety of criteria to narrow their searches and compare multiple therapists, including names, photos, bios and specialties of therapists.
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Therapist must be available for an appointment
Availability of a therapist played a significant role in interview and survey participants' selection. Half (4 of 8) of interviewees were concerned with finding therapists who had flexible hours since they needed to prioritize their work and school schedules. Riley said, “A lot of times they have normal work hours and if you don't work for a company where your schedule is flexible, it can be really hard to schedule appointments”. 74% of survey respondents said appointment times that fit their schedules were very important (16 of 31) or important (7 of 31).
Half (4 of 8) of interviewees indicated there was a sense of urgency in finding a therapist. Appointment availability was considered urgent when participants were in a compromised mental state and felt they could not wait for an extended period of time before their first therapy appointment. Carly recalled, “I was just so desperate and I needed help immediately. That was really important...if there was a really good recommended therapist but the wait was a month and a half, I wouldn't have gone to them”. Survey results supported this need. 52% of respondents said how soon they could meet with a therapist was a very important (7 of 31) or important (9 of 31) factor in their selection.
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Building a connection is built on preferences
Interviewees sought common ground with their therapists, to help them build connections, and create a safe space for sharing personal information. Specific qualities differed based on each participants’ goals, which could be categorized into seeking assistance with a specific psychological condition or a major life event.
The majority (7 of 8) of observation participants and most (7 of 8) interview participants were female and searched for female therapists, indicating a potential gender preference. Riley said, “I just feel a lot more comfortable talking to women than I do men. So one of my primary goals was just making sure that I had a female rather than a male therapist”. Hannah and Lisa searched for therapists who were the same race as them. Riley and Maria searched for young therapists, close to their ages.
Survey responses supported interview participants’ need for making a connection with their therapist. 65% of respondents indicated that therapeutic style was very important (17 of 31) or important (3 of 31).
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Insurance: Important regardless of reason for treatment
Insurance was a prevalent factor in the therapist search for observation, interview and survey participants. The majority (7 of 8) of observation participants and interview participants (7 of 8) identified the importance of finding a therapist who accepted their insurance plan.
The focus on insurance led 3 of 8 participants to search for therapists directly on insurance company websites. Two participants (Tom and Riley) mentioned the importance of insurance providers from a cost perspective. Valerie said the presence of familiar insurance carriers added “validation to therapy websites”. 5 of 8 interviewees utilized their insurance provider websites specifically to look for in-network therapists. Hannah said, “If they aren't covered at all and their cost is not something I can do, then I'm going to take them off my list. So I initially go to insurance and find out what's covered first”. Half of interviewees (4 of 8) said they left a therapist because their insurance or Employee Assistance Program benefits were no longer accepted.
A 5-point Likert scale (1=Not at all important, 5=Very important) was used to gauge the importance of insurance in participants’ selection of a therapist. The results showed that 63% of respondents considered covered by insurance as very important (15 of 31) or important (4 of 31). 61% of respondents (19 of 31) confirmed that the last therapist they saw accepted their insurance.
Of survey participants seeking therapeutic assistance for a psychological disorder, two-thirds considered insurance a very important factor (10 of 15), while only one-third of respondents seeking help with a life event responded the same (4 of 12).
We assessed the perceived importance of insurance by taking the scores of a 5-point LIkert scale (1=Not at all important, 5=Very important) as the dependent variable of a Mann-Whitney U test. Our grouping variables were survey participants whose last therapy appointment was covered by insurance (n=20) and participants whose last appointment was not covered by insurance (n=5). There was no significant difference in the perceived importance of insurance between the two groups at the alpha level 0.5 (u(23) = 74.5, Z = 1.71 , p = 0.088). The mean ranks of individuals with and without insurance coverage was 11.78 and 17.9 respectively. This does indicate statistical significance.
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Desire to know more about the therapist
Observation participants and interviewees compared therapist credentials and specialties. Half (4 of 8) of observation participants looked at years of experience and educational backgrounds of therapists. They examined schools that therapists attended, specific degrees and academic distinctions. All eight participants searched for bios to learn more about the therapists they found, which included information about the types of patients treated, and areas of specialty.
Half (4 of 8) interviewees sought out therapists with specific specialties, such as treatment for depression and anxiety or experience with specialized groups like families and LGBT individuals. 55% of respondents indicated that credentials were very important (6 of 31) or important (11 of 31).
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Location is important
Location was a key factor in selecting a therapist for interview and survey participants. The majority (7 of 8) of interview participants said location was a deciding factor in their selection. They looked for therapists near their homes, workplaces or schools. 68% of survey respondents said location was very important (9 of 31) or important (12 of 31).
Common Challenges
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Some information is hard to judge online
Even when observation and interview participants could find basic contact, insurance, cost and appointment information for a therapist, the available information did not help them understand therapists’ personalities and communication styles. Observation participant Valerie mentioned, “There are just certain things that you can’t really tell online, like trustworthiness and bedside manner”.
Half (4 of 8) of interviewees said information about personality and therapeutic approach were necessary to give them an idea if they would connect with a therapist or not. These interviewees acknowledged that getting a feel for these qualities before meeting them a therapist in person was challenging, since this type of information was often unavailable or did not translate online. Lisa explained, “It's hard to decide on a therapist until you've met them face to face and yeah, just get an idea of who they are, what they're like, their communication style”.
When asked how confident they were that the last therapist they chose would be a good fit for their needs, 42% of survey respondents indicated they were very confident (10 of 31) or confident (3 of 31), though 61% of respondents said knowing whether or not a therapist would be a good fit was very challenging (14 of 31) or challenging (5 of 31).
We conducted a Mann-Whitney U test to compare the perceived difficulty of searching for a therapist between participants seeking help for psychological disorders (n=16) versus those seeking treatment because of a life event (n=11). There was a significant difference of the medians of perceived difficulty between psychological disorder and life event participants at the alpha level 0.5 (u(25) = 89, Z = 0.05 , p = 0.96). The mean ranks of participants seeking help with psychological disorders and life events was 14.06 and 13.91, respectively.
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Finding the right fit can take trial & error
Observation and Interview participants mentioned that they were looking for therapists whose approach and personalities would compliment their own, and help them achieve their therapy goals. Dee explained, “What do you expect out of this? You need to have an answer for that because that's when you're going to find out what kind of therapist you have”.
Half (4 of 8) of interviewees said they needed to feel comfortable speaking openly and feel that they were in a safe space with their therapist. Connecting with a therapist through common backgrounds and interests gave participants more confidence that they could build a relationship with that therapist. 3 of 8 interviewees mentioned they were looking for therapists to hold them accountable, and take the lead in sessions.
Half (4 of 8) of interviewees said they were dissatisfied with their therapist’s communication or therapy style, and left to search for one that better matched their needs. They sought out therapists who were more attentive, provided motivational tools and implemented their preferred communication styles. Maria mentioned that even when she knew a therapist was the wrong fit, she struggled to decide if finding a new therapist was worth the effort: “It's like one, you have to make the conclusion that this probably isn't the right match for me. But then also the search process is so daunting that it's like, well, is it bad enough that I want to go back into that process?”
Switching therapists was common practice amongst interview and survey participants. The majority (6 of 8) of interviewees said they switched therapists because they were not the right fit. Four of eight interviewees said they thought trying multiple therapists before finding one they connected with was a natural part of finding the right therapist. Hannah said, “It's not an exact science, so finding someone is a puzzle...it's a process and sometimes that process can be because you start trying different people”.
Survey results indicated that 58% (18 of 31) of participants had switched therapists at some point. A 5-point Likert scale (1=Not at all important, 5=Very important) was used to gauge which factors were most influential in a participant’s decision to leave a therapist. 39% of respondents said a therapist who was not a good personality fit was a very important (8 of 31) or important (4 of 31) reason for leaving. This tied as the highest ranking reason for ending a relationship with a therapist, along with no longer needing a therapist. When asked how challenging it was for respondents to end a relationship with a therapist, 58% of respondents indicated that this was very easy (13 of 31) or easy (5 of 31). 81% of survey participants (25 of 31) said they ended a therapeutic relationship that was not a good fit.
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Once information is found, it's still not helpful
Searching for a therapist yielded a large number of results for observation and interview participants to sort through. 3 of 8 observation participants struggled to choose search terms that produced the results they were expecting and entered various terms until they found the information they were looking for. The educational degrees and certifications of therapists were confusing for observation participants Celeste and Valerie, who were unsure where to find clarification of how these aligned with specialties. Celeste said more information about this would help narrow her search.
The amount of information about therapists was overwhelming for some interviewees, especially those who were searching for a therapist for the first time. 3 of 8 participants mentioned that it was challenging to know where to begin their search for a therapist. Maria and Lisa said there was so much available information across multiple sources, that it was difficult to review. 3 of 8 interviewees, including Lisa, mentioned that their compromised mental state made the search process even more challenging, “When you're really in that depressed state, it's hard to do even the smallest things”. Similarly, survey results indicated that 32% of respondents found it very challenging (1 of 31) or challenging (9 of 31) to sort through and compare information from multiple sources.
In some cases, participants searched for more specific or personal information about therapists that was not readily available. The majority (6 of 8) of observation participants struggled to locate specific information they were looking for, which included therapist directories, specialties, therapist photos and customer reviews. When participants searched for reviews, they were often difficult to find or not from sources they considered credible.
In summary.
Selecting a therapist is an extremely personal experience based on the specific needs of each participant.
Participants took different approaches to searching for therapists, but focused primarily on online searches and personal references.
They narrowed their searches based on insurance, location, therapist availability, and therapeutic and communication style of therapists.
Even when participants selected therapists who met their search criteria, they found it difficult to know if they would have the type of connection they were seeking with a therapist before meeting them.
If patients did not think that their therapist was a good match, they often continued their search for a better fit.
Personas & Scenarios for Mental Match: An App Helping Patients Find a Therapist
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Experienced Emma
Emma is a 20 year old fine art student at the University of California, LA. Over a period of time, she developed anxiety problems which resulted in depression. She has been meeting with therapists off and on since she was a teenager and her last therapist appointment was 2 years ago. Emma had felt good enough to end her therapy sessions at the time, but she has recently been struggling to feel like herself. She has been feeling anxious and experiencing insomnia, which is making it hard for her to keep up with her schoolwork. She wants to find a therapist that she connects with, even if it takes her a little longer to find the perfect fit.
Emma discovered Mental Match through an online search and downloaded it. She filtered her therapist search based on insurance, location and gender of the therapist, because she is most comfortable speaking with women. When she found a therapist that met her qualifications, she booked an appointment with the therapist, then attended her first session. Because Emma had seen several therapists before, she immediately recognized that this therapist’s approach would not work for her. She used the break up form in the app to discontinue her appointments with the therapist. Emma appreciated this feature because her anxiety had made it difficult to confront therapists who were not a good fit, and end relationships with them in the past.
When Emma returned to the Mental Match app to search again, she realized she could chat with a therapist before meeting at the appointment. She had an online chat with a therapist she was interested in, and explained what she was looking for in her therapist’s approach and personality. She felt fairly confident that she found the perfect match after their conversation.
After her first successful therapy appointment, Emma added positive reviews and commented on the therapy style under the review section to help other therapy seekers learn more about her therapist. She also suggested Mental Match to family and friends searching for a therapist.
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Marriage Troubles Molly
Molly is a 30 year contract lawyer in Chicago, Illinois who is going through marriage troubles and it is negatively impacting her work. Her relationship issues have been escalating over the past few months, so she feels like she and her partner need to see a therapist as soon as possible. Even though she has been to therapy before, she has never seen a therapist with a partner, so she is unsure how to begin her search. An initial Google search for therapists who specialize in marital relationships produces an overwhelming number of results, which Molly is unsure how to analyze. She is frustrated by the variety of credentials attached to therapists and does not know what they mean.
Molly quickly gives up on using the internet to find a therapist, and turns to her family and friends for personal referrals. A friend suggests checking the Mental Match app, which she had used recently to search for a family therapist based on different criterias like therapeutic style, qualifications and availability.
Molly downloads the Mental Match app and discovers a credential dictionary that she references to learn more about the therapists she is considering. She filters her search to therapists who focus on marital relationships and have immediate availability. Molly uses the chat feature so she and her partner can speak to the therapist Molly is most interested in before booking their first appointment. This gives them confidence that they will both be comfortable with the therapist they chatted with, and Molly books their first appointment.
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Sad Sarah
Sarah is a 25 year old freelancing graphic designer and Master’s candidate in New York, NY. Juggling school and her full-time job has left her feeling very stressed and she’s stopped seeing her friends.
After her friends reach out asking if she’s okay, Sarah realizes she’s developed social anxiety and is showing signs of depression. Her friends help her realize she should seek help. Sarah is unsure of where to start and doesn’t have the emotional energy to aimlessly search, so she makes an appointment with her General Practitioner to talk through her options.
On her way to the appointment, Sarah sees an advertisement for Mental Match on the subway. She looks up the app and sees that she can make appointments with therapists that take her insurance. Once she arrives at the doctor’s office, she explains her symptoms and her doctor provides a referral.
On her way home, Sarah downloads Mental Match to make the appointment, but after searching, she realizes the therapist is not covered by her insurance. She then uses the app to search for an in-network practitioner. The app returns 10 results and Sarah filters the list down to only include therapists within walking distance of her apartment. She uses the credential dictionary to determine who might be similar to the referral her doctor provided. She identifies two therapists that fit her criteria and decides to make an appointment with the therapist who has the soonest availability. Sarah makes an appointment through the app and completes the digital intake form.
Later in the day, her client requests a meeting conflicting with her appointment, so she uses the app to reschedule her appointment. After she meets with her therapist for the first time, the app prompts her to rate various qualities of the interaction including level of attention provided and bedside manner.
Feature List
We identified which features to include in our new product and determined who would be the primary user of each.
