@DrQuinn So a lot of this is because insurance is a headache to deal with as a therapist. Often insurance will require you to provide them with your progress notes as well as your intake summary. Some private practice folks I know who work with the bigger firms will also have a required “case consultation” with them (bogus term since case consultation is intended to be between mental health workers or physicians) where an underwriter will evaluate whether therapy is progressing properly. Insurance companies also pay less, from a materialistic perspective. As Marxist as I am, I still have $250,000 of student debt and that’s about the average these days.
Additionally, most outpatient therapists don’t use instruments to track progress. In inpatient (and at my current intensive outpatient place) we use various metrics – typically the GAD-7, PHQ-9 or BDI, and PCL-5 – to evaluate for anxiety, depression, or trauma symptoms respectively on a weekly basis. The return rate in inpatient and IOP is pretty low, probably natively around 40% at the VA, and we get about a 60-ish% return rate where I am now, so it’s a lot of hounding people “did you fill out the weekly form? Don’t forget to fill out the form” because it’s often a requirement by insurance companies.
In California, we have the mental health parity act, which is generally a good thing as it prevents therapists (or “coaches” in the worst case scenario) from practicing non-evidence based treatment. However, it also allows insurance companies to say “you’re going to use CBT for this patient.” Even if you’re working with, say, a person who has bipolar disorder and borderline personality disorder and would better serve them by using DBT or (maybe) acceptance and commitment therapy, the insurance companies know that CBT has a wife body of literature showing it to be effective insofar as it becomes a shotgun approach to treatment. CBT is effective for many things; CBT is also very ineffective for many things. CBT has an added benefit for the money people of having between 12-16 sessions for clinically significant change (with specific illnesses).
Research backs up the use of CBT as well. Depression and anxiety are also the most common mental illnesses in the US (probably the West in general), and usually receive the lion’s share of attention by researchers, who will typically use CBT because it’s quick to implement and fairly easy to learn, which means we have a research corpus that includes so much research on the effectiveness of CBT and a lot of papers that have to reiterate that ACT, DBT, CPT, TLDP, AEDP, other alphabet soup acronyms, etc. are as effective if not moreso than CBT in specific situations and within cultures. I didn’t touch on culture, but that’s just another big blind spot in the field.
None of this is intended to be an excuse, but a remonstration of the American medical and mental health system. All of this sucks and we’re aware.