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Reading the Signs
According to the survey, the average licensed counselor, social worker, or marriage and family therapist in full-time private practice is earning a "salary" or net profit—income minus hefty practice expenses—of only $30,000 a year. The main reason for the drop in income is that managed-care fees for individual sessions, which account for 43 percent of the average practitioner's income, haven't risen for a decade, languishing at around $75 at the high end and $60 at the low end for a 50-minute session.
It's not that there isn't enough money: according to Plunkett Research, a company that specializes in health care market analysis, health spending in the U.S. is at about 16 percent of the gross domestic product, and growing. But the money funnels primarily through managed care delivery systems, which are disinclined to promote mental health. John Klein, editor of Psychotherapy Finances, notes that 15 years ago, the health care consultants he talked to found that 10 percent of all insurance dollars went to pay for mental health services. "Today, the figure I hear from the consultants is closer to 1.5 percent," he says, sounding discouraged.
Some psychotherapists stay above the fray, free of managed care (especially in metropolitan areas, such as New York; Washington, D.C.; and San Francisco), but even they face a good-news-bad-news situation. The good news is that self-pay fees are up: marriage and family therapists can ask for and get on average $100 from self-pay clients, as opposed to $75 in 1997. But the self-pay market itself is eroding, making up less than 33 percent of the average psychotherapist's practice. Psychotherapy Finances found that self-pay clients fell from a high of 44 percent of therapists' caseloads in 2000 to just 26 percent in 2006. Psychotherapy has always been a tough sell. Even though the 1999 Surgeon General's Report on Mental Health stated that 1 in 2 Americans has a diagnosable mental disorder in any given year, it found that fewer than half of all adults and one third of children seek help. A study in the February 2000 Journal of Psychiatric Services showed that the majority of the population didn't understand their health plan's mental health benefits, and that the concept of getting treatment was misunderstood and feared, and conveyed feelings of stigmatization.
The market of potential clients may be weakened by a siphoning-off effect from other types of healing professionals, such as alternative health care practitioners who offer energy work, bodywork, nutrition, and life coaching as treatments for stress, low-level depression, anxiety, and other problems that used to be the purview of psychotherapy. A therapist in Pittsburgh said a new client diagnosed with dysthymia called to cancel her sessions after the first month, saying she was "feeling much better by just going to a weekly meditation class," and would rather use her money for that purpose.