Commentary on “You will be better soon: Manipulating Patients to Continue Psychotherapy Treatment”
This Letter to the Editor by Kadir Uludag, published in Med Discoveries, raises a pointed and ethically significant critique of psychotherapy practice, particularly within private clinical settings. The author argues that the absence of clear, objective measures for therapeutic progress—combined with financial incentives—may lead some psychotherapists to consciously or subconsciously prolong treatment beyond what is clinically necessary or beneficial.
Core Argument and Its Merits
Uludag’s central thesis addresses a genuine ethical gray area in mental healthcare. The concern that therapists might delay termination for financial gain is not merely speculative; it touches upon fundamental issues of trust, power dynamics, and the commodification of care. The argument is built on several logical premises:
-
Measurement Problem: Psychological improvement is often subjective and difficult to quantify with perfect consistency. This ambiguity creates a vacuum where clinical judgment can be influenced by non-clinical factors.
-
Conflict of Interest: In a fee-for-service private practice model, therapist income is directly tied to the number of sessions. This creates a structural incentive to continue treatment, a conflict between the clinician’s fiduciary duty and their financial interest.
-
Vulnerability of Clients: Patients seeking therapy are often in states of distress and may have diminished capacity to evaluate their own progress, making them potentially susceptible to a trusted authority figure’s suggestion that they need more care.
By highlighting these points, Uludag usefully directs attention to the need for greater transparency and accountability in psychotherapy. The proposed solutions—regularized progress reporting, client confirmation of goals, and external monitoring after a certain duration—are constructive starting points for discussion on safeguarding therapeutic integrity.
Critical Analysis and Limitations
While the letter raises a crucial issue, its format as a commentary necessarily limits its depth and evidentiary support. Several aspects warrant critical consideration:
-
Generalization and Tone: The title and argument risk overgeneralizing. The term “manipulating” is ethically loaded and implies widespread intentional misconduct, a claim that would require substantial empirical evidence about therapist behavior across the field. Most ethical frameworks in psychology (e.g., APA ethics codes) explicitly prohibit such exploitation, and many therapists actively engage in collaborative termination planning.
-
Oversimplification of Termination: The decision to end therapy is complex and multifaceted. It involves not just symptom remission but factors like relapse prevention, consolidation of skills, the therapeutic relationship itself, and the client’s own sense of readiness. The letter frames this primarily as a decision based on measurable “output,” which may not capture the full therapeutic process.
-
Lack of Empirical Support for the Core Claim: The letter cites literature on therapy duration and client dissatisfaction but does not provide direct evidence that financial manipulation is a common or systemic problem. The referenced study by King (2015) suggesting an inverse correlation between duration and outcome is intriguing but contextual; it does not establish causation or prove that longer therapy is typically driven by therapist profit motive.
-
Structural Focus on Private Practice: The critique is aimed squarely at private clinics, implicitly suggesting other settings (e.g., institutional, community health) are less susceptible. This is a valid distinction, but unethical prolongation could theoretically occur in any system where provider metrics are tied to service volume.
Context and Contribution
Uludag’s letter serves a valuable function within the broader discourse on mental healthcare ethics. It acts as a provocative call for vigilance. Even if the scale of intentional manipulation is debated, the underlying structural conflict of interest is real. The commentary echoes long-standing debates in medicine about fee-for-service models and the importance of external audits and standardized outcome measures (e.g., routine outcome monitoring) to align provider incentives with patient welfare.
Conclusion
“You will be better soon” succeeds in putting a pointed finger on a sensitive and important pressure point in psychotherapy practice. Its strength lies in its willingness to articulate an uncomfortable ethical concern that often remains undiscussed. However, its impact is somewhat blunted by its polemical tone and lack of direct evidence for its central accusation of widespread manipulation.
The letter is best read not as an empirical indictment of the profession, but as a thought-provoking ethical commentary. It reminds clinicians of the need for rigorous self-reflection on their termination practices and strengthens the case for the field to develop more robust, transparent, and client-verified methods of evaluating progress. Ultimately, it underscores that the ethical practice of psychotherapy requires constant navigation of the tension between clinical judgment, client autonomy, and the economic structures within which therapy occurs.
