Most people who fire their psychiatrist or therapist wait about a year too long to do it. They sit through appointment after appointment, refilling something that isn’t quite working, talking through the same set of problems with someone who keeps nodding, and the whole time a quiet voice in the back of their head is saying this isn’t going anywhere. And they ignore it. Because the alternative is starting over, and starting over is exhausting.
So the bar gets lower. They tell themselves the provider is “fine.” They stop tracking whether they’re actually getting better. A year goes by. Two. Sometimes five.
Not all mental health providers are equally good. Some are excellent. Some are mediocre. Some are actively unhelpful. You deserve to know whether the person you’re seeing is helping or if you should find someone else.
The annoying truth is that you can usually tell within four or five visits whether the person across from you is paying attention. The signals are small. Whether your therapist references something you said in the third week when you’re in the eleventh. Whether the med list on their screen matches what’s in your bottle, or whether they’re still asking about a drug you stopped two months ago.
What an engaged prescriber actually looks like
A psychiatrist who’s doing the job will, at minimum, do this: read your chart before you walk in, name your meds and doses without looking, ask one specific follow-up question about something you brought up last time, and tell you what they’re changing and why in language you can repeat back to a friend.
That’s the floor. Below that floor, you’re paying for a refill button with a person attached.
Above that floor it gets more interesting. The good ones track side effects on a real timeline. They’ll say something like “we’re at week three on the Lexapro, the GI stuff should be easing off, the libido stuff probably isn’t going to budge without us doing something about it.” They’ll say “I don’t know” out loud when they don’t know, which sounds like a small thing and isn’t.
I had a woman come in last spring, early fifties, who’d been on the same 20mg fluoxetine dose for eleven years. Eleven years. Her previous psychiatrist had refilled it through the pandemic over the phone without ever asking whether it was still working. It wasn’t. She’d been low-grade depressed for at least four of those years and had assumed that was her baseline now. When we changed it, the difference inside six weeks was the kind of thing she described as “remembering I have a personality.” Her old psychiatrist wasn’t malicious. He was on autopilot, and she’d been polite enough to never push.
That’s the most common failure mode. Not malpractice. Drift. The appointment becomes a ritual, the medication becomes wallpaper, and nobody asks the obvious question.
Signals that you’re getting actual treatment
You feel slightly uncomfortable sometimes. Not all the time. But the good ones will push on something. They’ll say “you’ve mentioned your father three times now and every time you change the subject” or “I notice we keep talking about your boss but you came in saying you wanted to address the drinking.” If every session feels like a warm bath, you’re not in treatment. You’re in a friendship with a copay.
You have a working hypothesis about what’s wrong. Not a final answer. A working one. “We think this is mostly anxiety with some ADHD underneath, we’re treating the anxiety first because the SSRI also helps if the ADHD piece turns out to be smaller than I think, we’ll reassess in eight weeks.” If you can’t summarize the plan, the plan probably doesn’t exist.
You know what you’re tracking. Sleep. Panic frequency. Number of drinks per week. Whether you cried at work this month. Whether you can read a book again. Something specific. If “how are you doing” gets answered with “fine, I guess” every visit and nobody’s pushing for better data, you’re not measuring anything, and if you’re not measuring anything you can’t tell whether the treatment is working.
A good provider gives you opinions you didn’t ask for. A great one explains why, then leaves the decision with you.
You feel like a person to them. This is fuzzier and harder to defend but you know it when it’s missing. Do they remember your dog’s name. Did they catch that the holidays are the bad season for you. Pattern recognition is what makes this field work, and you can’t pattern-recognize a person you’ve never bothered to see.
Markers that someone is phoning it in
The appointment is identical every time. Same three questions. Same prescription. Same “see you in three months.” The only thing that varies is which couch you happen to be sitting on.
They never adjust the dose. You’ve been on 50mg of Zoloft for two years and it’s working “okay.” Nobody’s asked whether “okay” should be the target. Nobody’s tried 75mg or 100mg. Nobody’s asked whether you’d like to try coming off and see what happens. The med has become furniture.
They can’t tell you the plan. Ask them, in plain language, what you’re working on and what success would look like. If the answer is vague, defensive, or routes through jargon you don’t understand, the plan isn’t real.
They don’t talk to your other providers. Your therapist and your prescriber and your primary care should be exchanging at least one note a year, with your permission. Siloed care is how someone ends up on three medications that interact badly because no one was looking at the whole picture.
They get defensive when you push. A confident clinician is fine with being challenged. Someone who bristles when you ask a basic question is telling you something important about how the rest of the relationship is going to go.
They name the trade-off
A prescriber who says “this dose will probably help the anxiety but the sexual side effects are real, here’s what we can do if they show up” is doing the job. The bad ones leave the side effects for you to discover at 3 AM.
Twelve-minute med checks
If every visit is rushed and the questions are identical (sleep, appetite, suicidal thoughts, next), you’re getting a billing template, not an evaluation. Real med management takes 20-30 minutes minimum once you’re past the intake.
Say it out loud
“I don’t think this is working.” Watch what happens. A good provider gets curious. A mediocre one gets defensive. A bad one gets bored. You’ll learn more in that five-minute conversation than in the previous five appointments combined.
What to do if you’re not sure
First, say it. Out loud, in the room. “I don’t feel like we’re getting anywhere” is a complete sentence. Watch what comes back. If the provider gets curious, asks what’s been off, suggests something concrete to try, that’s the response of someone who’s still in the work with you. If they get defensive or repeat the same plan louder, you have your answer.
Second, give the new approach a real window. Six to eight weeks for a medication change. Four to six sessions for a therapy adjustment. Not “let’s see how it goes” with no endpoint. A real window with a real check-in at the end.
Third, if nothing changes, switch. The fear is that switching means starting over and losing everything you’ve built. The reality is that if you’ve spent two years not getting better, you haven’t built much, and the thing you’ll lose by leaving is mostly the sunk-cost feeling. A new provider with fresh eyes can sometimes move things in three months that the previous one couldn’t move in three years.
Don’t quit treatment because one person wasn’t right. That’s the thing people do that I wish they wouldn’t. One bad fit becomes “psychiatry doesn’t work for me,” which becomes another decade of white-knuckling through whatever is going on. The right provider isn’t magic. They’re just the one who actually pays attention.
If you’ve been seeing someone for a year and you can’t name three specific things that have gotten better, that’s not a moral failing on your part. It’s data. Use it.