The Quiet Crisis in Mental Health: The Medicalization and Deskilling of Psychotherapy

The medicalization of psychotherapy has undoubtedly been influenced by the psychiatric establishment’s “revolution” in 1980, marked by the release of the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III). A manual barely known to the public before 1980 has since become a hegemonic force, shaping not only the practice of psychotherapy but also the broader cultural understanding of psychological suffering as “biomedical.”

DSM diagnoses are now widely accepted as “universal” and “fixed biomedical” disorders by both the general public and most mental health professionals. In reality, however, many of these so-called “disorders” reflect cultural and socio-political constructions of suffering, particularly specific to the United States. Even the DSM-IV committee chairman, Dr. Allen Frances, once admitted, “You cannot define mental disorders, it’s bullshit.”

This “bullshit,” however, dominates insurance reimbursement practices, requiring all mental health professionals—even those without medical degrees—to use DSM diagnoses as a medical framework for both billing and treatment. This biomedical model has fueled the rise of so-called “evidence-based” psychotherapies, which are promoted by insurance companies under the premise of “standardizing” care.

These treatments are designed to resemble medical interventions by focusing on measurable symptom reduction aligned with DSM criteria of disorders. They are often conveniently time-limited, making them more cost-effective for insurers. In this way, for-profit companies have undermined clinical autonomy and expertise by dictating and influencing treatment decisions—decisions that should rest with trained professionals.  Many clinicians have now bought into this way of viewing mental health and its treatment as a universal model.

Yet, the rise of “evidence-based therapies,” intended to standardize care according to a biomedical model, has paradoxically undermined the skill and practice of the psychotherapy profession rather than improved it. As psychotherapy becomes increasingly “standardized” and medicalized, practitioners are reduced to technicians who apply protocols to reduce symptoms rather than clinicians who engage in dynamic, process-based, and individualized therapeutic work. Evidence-based rhetoric creates the illusion that any clinician can deliver the same standardized treatment. But psychotherapy is not—and never will be—a one-size-fits-all approach.

The well-known psychoanalyst Nancy McWilliams argues that while most clinicians can agree that psychotherapy should be informed by research, it cannot be like research, which is an unspoken assumption at the heart of the evidence-based craze. The problem, as she further explains, is that while DSM categories and quantitative treatment methods (such as behavioral therapies) are valuable for research due to their measurable and objective nature, subjective suffering is far more relevant in actual treatment settings.

McWilliams also highlights another conflict: research on evidence-based therapies is often conducted with (for lack of better terminology) “higher-functioning, cooperative” individuals, for whom nearly any therapy tends to be effective. As a result, findings on what qualifies as “evidence-based” may not apply to individuals with complex characterological traits or serious mental illnesses,¹ the very people who need treatment the most.

The psychotherapy profession has long been criticized for prioritizing the “worried well” or YAVIS patients (Young, Attractive, Verbal, Intelligent, and Successful) while neglecting individuals with serious mental illness. This critique is relevant now more than ever as private practice expands alongside the overall deskilling of the profession. And because many therapists now believe that mental illnesses have a biological or physiological basis, they view individuals with more severe mental health issues as benefiting from psychiatric care more than psychotherapy. As a result, this promotes the funneling of the “mad” toward psychiatry and institutional care.

This parallels Micha Frazer-Carroll’s argument that mainstream “mental health awareness” campaigns tend to normalize mental illness for the so-called “worried well,” while deliberately excluding those deemed “mad” or seriously mentally ill. The “worried well” are portrayed as non-threatening, fixable, and capable of returning to “productivity” through “hard work” (and SSRIs)—in contrast to the “mad,” whose personality structures and experiences of self cannot be easily aligned with capitalist ideals of productivity and exploitability. As a result, Frazer-Carroll contends that these individuals are often regarded as unsalvageable—justifying the incarceration of those living with serious mental illness. I would add that this narrative also legitimizes other forms of control, such as psychopharmacological sedation and broader mechanisms of state violence and institutional surveillance.

This trend parallels the troubling increase in licensed but inadequately trained therapists. Many of these professionals hold degrees in Social Work or Mental Health Counseling. As the field increasingly shifts towards prioritizing quantity by rapidly producing therapists (in 2-year degrees) to meet market demands in response to the perceived ‘mental health crisis’ of the country, it has done so at the expense of advancing professional competencies and nurturing rigorous long-term clinical development that is necessary for clinicians. The lack of training for many of these clinicians is not merely an issue of lack of individual preparation or failure (they are not to be blamed) but rather a systemic problem shaped by market forces that prioritize numbers over meaningful clinical training.

In addition, there seems to be sheer silence by more experienced clinicians (who are in the mentorship phases of their careers), who should ideally be critically voicing concerns about these systemic processes, the exploitation of early career clinicians, the changes in mental health professions (like social work) and the overall lack of accessible mentorship, training and clinical supervision available to early career professionals.

In this context, the emergence of the “online weekend side-gig therapist” has become a trend. Many of these therapists, unprepared for the complexities of clinical work, are often drawn into the field due to economic necessity (as secondary incomes) and are exploited by corporations like BetterHelp, who are more interested in profits than the quality of care. As a result, “side-gig” therapists often find themselves catering to the “worried well” while lacking the skills to address the more severe and complex cases.

On the flip side, it’s not uncommon for more experienced therapists in private practice to dismiss individuals with severe mental health issues, labeling them as “too much of a liability” or even “beyond help.” This dismissive attitude reflects a larger pattern where these systems, fueled by market demands, fail to properly support and prepare both therapists and patients, especially patients with more complex needs.

The psychologist Marsha Linehan points out that an additional unspoken layer to this dilemma is that therapists are not paid more for working with patients who experience more intense suffering, disorganized self-states, complex personality organizations, and/or serious mental illnesses. This lack of financial incentive further discourages the treatment of those who are profoundly suffering and may require more attention by the clinician, often leaving this type of work to clinicians who feel a deep calling for it but do not get additional financial reimbursement, support, or recognition.

The mental health field is increasingly shaped by economic forces prioritizing quantity over: quality care, fair compensation, and accessible clinical training/ mentorship for clinicians. It is no secret that insurance companies favor social workers and licensed mental health counselors due to being able to provide them with lower reimbursement rates. Needless to say, in private practice (and in community health) insurance reimbursements are deeply exploitative, forcing the therapists who do accept insurance or reduced fees to work significantly longer hours than those who operate on private pay. This financial strain contributes to an increased therapy caseload in private practice (also an impossible and unethical caseload in community health), which incentivizes high patient turnover and discouragement of depth-oriented work. In addition, in private practice, accepting insurance can lead to resentment towards patients, especially if the patients are high earners and could pay full fee, but still use insurance, as many therapists who take insurance earn less than their patients! This highly stressful and precarious economic work environment contributes to the overall deskilling of the profession and the need to fend for oneself as a business rather than a humanistic discipline.

Another factor of concern for private practice therapists is that without access to public/universal health insurance, they must cover their personal health insurance (thousands per month), unlike employed clinicians. In addition, private practice therapists must cover the costs of liability insurance, exorbitant and ever-increasing office rental costs, etc. After all is said and done maintaining your private practice, some therapists who provide sliding scale fees or accept insurance are making $25 per hour. This financial reality forces many psychotherapists to charge higher fees or work excessive hours.

As a result, private practice psychotherapy becomes less accessible, further deepening inequalities within the field. I find it interesting that professionals, institutions, and politicians often advocate for “mental health awareness” and the “destigmatization of therapy/mental illness,” yet rarely discuss the urgent need for fair pay for therapists—both in private practice and community health—as a critical first step toward expanding access to mental health services. Without addressing financial compensation for mental health providers, any effort to broaden access to mental health services will contribute to the already difficult working conditions many psychotherapists face, keep many locked in precarious conditions and force others to charge higher fees, making it less and less accessible, as therapists will continue to be unable to reach the communities most in need.

In today’s market-driven mental health field, depth-oriented training—once essential for addressing complex psychological issues—is increasingly devalued. Traditionally rooted in psychoanalytic and psychodynamic traditions, such training has been overshadowed by economic pressures, the high cost of postgraduate education, clinical supervision, and personal therapy, as well as lack of diversity in faculty in these institutes. These barriers prevent many clinicians from accessing the rigorous training or from affording the out-of-pocket costs for clinical supervision—both of which are essential for the ongoing, lifelong process of becoming competent psychotherapists. Instead, therapists are incentivized to piece together fragmented knowledge of “evidence-based” modalities through Continuing Education Units (CEUs) acquisition, often provided by profit-driven companies like PESI. These courses prioritize marketability over clinical substance, raising licensure maintenance costs while promoting superficial engagement with therapeutic models.

Today, the divide in the profession is no longer about the historical split between behavioral and psychodynamic approaches but rather between the therapist trained in a modality and the therapist not trained in one. Many clinicians now offer therapy as a generalized or generic service, referencing terms like CBT, DBT, relational/ talk therapy, or trauma-informed care without formal training or a coherent framework. Some even claim expertise after a weekend workshop or a few classes, contributing to a field where foundational competence is increasingly rare.

This lack of standardized training creates a disorienting array of services provided by psychotherapists— where some provide psychoanalytic or psychodynamic treatment, others DBT, while others provide energy healing, nutritional advice, tarot readings, and even ketamine-assisted therapy. I recently ran into a licensed clinical social worker online who advertised themself as a “Psychotherapist/Psychic/Healer” (talk about a transference cure!) While various approaches to treatment are not necessarily bad, overall, it blurs the definition of what psychotherapy is and confuses patients seeking effective care.

While ‘evidence-based’ therapies aim to address the inconsistencies mentioned above, the commercialization of how these therapies are taught by market-driven businesses—often as a buffet of “evidence-based modalities”—along with the buffet style learning in accelerated 2-year master’s degree programs, has only fueled these inconsistencies. However, as long as clinicians include the right “evidence-based” buzzwords in their notes—often dictated by insurance requirements—their work is labeled “evidence-based,” regardless of whether they meaningfully apply the modality.

This dilution of professional standards has become a quiet crisis, largely ignored and indirectly reinforced by CEU-driven education. Still, the profession continues to play along in the charade. Trained therapists, as well as students quick to catch on, often recognize the disconnect—while many untrained clinicians remain unaware that simply naming a therapy doesn’t mean they’re practicing it. For instance, some believe they’re providing CBT because they use a worksheet from time to time, while others claim to offer DBT because they incorporate mindfulness. Others identify as providing “relational therapy” simply because they’re empathic or act as a “good object” for the patient. These surface-level applications mask the growing gap between therapeutic labels and actual clinical practice.

Fast-track certifications and accelerated clinical degree programs reduce therapy to a mix of buzzwords, enabling therapists to meet insurance documentation standards without true understanding or application. This performance of competence masks a deeper professional crisis: the erosion of standards and clarity in clinical work. Ultimately, the field faces a growing fragmentation that disorients both clinicians and clients, making it nearly impossible for patients to differentiate between the various types of licensing, training, techniques, modalities, etc. that exist. This makes it challenging for patients to choose what type of treatment to partake in that would fit their needs and often find the right therapy/modality by chance.

Mainstream psychotherapy discourse and market forces increasingly pressure therapists to self-market and commodify themselves (often using their identities, “affirming” language, and other therapeutic buzzwords), reducing the profession to a competitive enterprise.  In short, this creates a cycle of gaslighting around therapeutic modalities for patients and therapists, where patients are confused about effective care, therapists face impossible expectations, and the system profits by sidelining real progress. It invalidates both the therapist’s expertise and patient’s experiences, prioritizing the DSM and the billion-dollar mental health industry. As a result, everyone is caught in a system that doesn’t make sense, fails to prioritize mental health, and serves only the bottom line, both profit and neoliberal ideologies.

Without addressing commodification, market expansion, the dominance of psychiatry and insurance companies, and the exploitation of newer (and experienced) clinicians, psychotherapy risks becoming a profit-driven industry that serves socio-political and economic interests rather than a professional discipline or those it aims to help. We need new ways to critique the medicalization and deskilling of psychotherapy—approaches that go beyond opposing mainstream trends and truly break from them. This starts with an honest, macro-level analysis of where the profession has been and where it stands today, requiring a willingness to critique both our field and ourselves.

Behind the contemporary buzz of mental health awareness and promotion of services, there hides a profession in crisis. We must not remain silent about it. If we are to restore the integrity of mental health services, we must confront these processes head-on to reclaim and redefine it as a practice that challenges, rather than reinforces, the systems of power that perpetuate harm and commodify experience. While criticism seeks to identify faults to blame, critique, on the other hand, encourages us to examine the flawed logic within a system, phenomenon, or argument, as such opening us up to new solutions. If we interpret the need for a critique of the profession as personal criticism or attack, we risk shutting ourselves off from self-reflection and growth, as well as from using our work as a genuinely liberatory practice. We must support each other in this endeavor of self-reflection.