I just received this e-mail from Ann, a psychotherapist in Washington State: “Casey, for the first time in my 15-year practice, I’m starting to get really scared. At first, a few clients decided to ‘take a break’ and stopped coming. Then a few more moved from weekly sessions to every other week. I’ve just balanced my books and realized that I’m making only half of what I did this time last year. What can I do to get my caseload back to where it was before?”
Last week, I had a call from Charlotte, a psychologist in northern California. She, too, said her caseload was down almost 50 percent: “I’m still getting calls asking if I’m taking clients,” she told me, “but these calls are few and far between. When I do get new clients, they come once or twice and then realize they can’t afford it. I’m starting to negotiate and lower my fees. I need to make at least enough to pay my rent. What can I do to get more clients who can afford therapy?”
The note of desperation in these e-mails is hard to miss. Ann and Charlotte aren’t alone. I speak with private practitioners all over the world, and the mood out there is somber. The resounding chorus from private practitioners everywhere is the same: “This economy is killing me! I need more clients. How do I find them and get them in the door?”
Over the years, business coaches (including me) have produced an avalanche of books, articles, courses, and workshops on how to build a bigger private practice and recession-proof it. The goal of their advice is always the same: teaching therapists—traditionally allergic to doing anything that smacks of “selling” themselves—the marketing skills that’ll draw more private-pay clients to their waiting rooms. The question to which therapists tirelessly address themselves and their efforts is and always has been: “What can we do to fill more private-session hours?”
What’s the Real Question?
Now I’m wondering if this isn’t the wrong question. In the economic tsunami threatening to overwhelm us, it begins to seem that the right question isn’t “How do I get more individual clients?” That just boils down to “How do I do more of the same?” Perhaps the real question should be “How do I do meaningful clinical work and sustain a good income over the short and long term, regardless of the economy?” Notice that this question makes no mention of attracting individual, private-pay clients.
It now seems to me that the way we automatically think of building and maintaining a therapy practice may no longer be an economically viable way of sustaining ourselves. For the past hundred years, psychotherapy has operated generally as the private meeting of one patient with one well-trained mental health expert for roughly one hour of presumably helpful conversation. Despite our attachment to this model, it isn’t the most efficient or creative way of helping people or of making money. Many therapists would like to help more people than they can responsibly jam into an 8-, 10-, or even 12-hour workday. Or they’d like to be able to do something for all the people needing help who can’t afford one-to-one therapy by the hour. Then there’s the money crunch: even if therapists raise their hourly fees, their total income won’t rise by much. In fact, trading hours for dollars means we have jobs, rather than independent businesses—jobs that don’t provide retirement plans, sick pay, or paid vacation days. Since our income reflects the number of in-person sessions we provide, a recession that constricts people’s sense that they can afford therapy can send our finances hurtling right off a cliff.
The New Zeitgeist
The economic downturn aside, the biggest problem with the old fee-for-service therapy model is that it isn’t in sync with social and cultural shifts in how increasing numbers of people think about therapy and therapists. those seeking psychological help today don’t think of themselves as patients, or even clients, as much as they consider themselves consumers or customers. They want to be served what they want, on their terms. When they have emotional or relationship problems, they look for a quick, effective solution, which will help them get through a tough time. They’re less interested in an intense, open-ended relationship with a highly trained stranger than with a practical, appealing, and reasonably priced product, one that’ll provide some short-term relief and maybe a little long-term wisdom.
One reason for the increasing impatience with standard therapy (besides cost, of course) is our Internet-reinforced demand for instant gratification. Last year, my mother-law became ill, and we needed help dealing with her dementia. I’d spent 10 years working with the geriatric psychiatric population, but when it was my family’s problem, I wanted information quickly. Therapy might have helped us through the crisis, but it would have taken a lot longer than the hour I spent searching the web to find helpful resources, including free checklists and articles, as well as downloadable material I could purchase online.
Today anybody facing nearly any life challenge can do the same thing—go online and within a day, an hour, or even minutes find that particularly helpful special report, audio recording, or book, and have it delivered instantly to their e-mail inbox. They can be reading or listening to solutions in the time it would have taken them to leave a message for a therapist. This means that therapists are competing with a flood of authors, coaches, lecturers, and other experts (and with enterprising quacks), all of whom offer various forms of self-help.
Another social transformation of our era is the almost universal time crunch; none of us ever has nearly enough of it. Taking a couple of hours from a busy day to go to a therapist for a personal session feels to many like a grossly inefficient use of time. It’s much more convenient to hire a life coach or relationship coach, open to spur-of-the-moment telephone and electronic “sessions.”
What to Do?
Some psychotherapists, seeing the writing on the wall, are responding by updating how they do one-to-one therapy to bring themselves more in line with what people want. They’re adding e-therapy, web chats, text or e-mail consultations. They’re offering phone sessions in hour-long and abbreviated formats—15-minute “laser” sessions, for example, to help clients get back on track after a disturbing interaction at home or at work.
The problem with these solutions is the method of delivery. While meeting the need to be more flexible, it still means that therapists can provide service to relatively few people at a time, which still limits their income and intensifies the struggle to get more clients in the door.
We need to get off the one-person-for-one-hour-for-one-fee track and think more broadly about what we can offer the world and how to communicate it to as many people as possible. We need to share our wisdom and knowledge in ways that serve the community while leveraging our time and energy. We need to devise a model that supports us when the economy is booming and doesn’t desert us when the economy is tanking.
Some years ago, I, too, was at a point where I was tired of hustling to get more clients into my practice, which was feeling more like a job than a vocation. This hit home one December when I felt burned out and needed time off to rest and reenergize. I began to think about the odd contradiction of our profession: we’re a helping profession, yet when we need to help ourselves, we do so at the expense of our income. I knew there had to be a better way. Then I discovered a business model that had been used successfully in other fields, most notably in the coaching profession: the Multiple Streams of Income model. I found it useful and decided to modify it for therapists.
Simply put, this model helps clinicians augment their in-person practice with “information products”—books, CDs, audiotapes, e-books, and e-courses—created once and then sold repeatedly. The products may be physical, but the power of the model comes from using the Internet to sell and deliver them. Using this model meets consumer demand for instant gratification; lets therapists help people who can’t afford therapy; extends therapists’ reach beyond their local communities; and offers dependable, additional income.
When implementing this model, some therapists choose to reduce the number of one-to-one hours and limit their in-person time to high-end workshops or retreats. Others choose to stop all clinical work and spend more time creating and selling products, or providing speaking and consulting services. The beauty of this model is that it can be adapted to each provider’s desires and personality.
Getting Started—the Lure of the Pink Spoon
The model makes sense, but will it work? Can clinicians compete in the oversaturated self-help market and still make a good living? People have been publishing self-help literature for decades. How can we break into that market?
You don’t do it by trying to get your idea published or produced by a big company; few are likely to take on the projects of an unknown psychotherapist. Not to worry! Technology has made it easy for independent practitioners to create downloadable written or audio products and compete with the big companies quickly and inexpensively.
You don’t have to start big; in fact, one of the charms of this approach is that it doesn’t require a huge commitment of time and money.
First, before you do anything else, identify a niche—the specific clients, group, issues, areas of therapy, or specialty that interests and excites you. Let’s say you love working with kids and are particularly concerned about school bullying—something you emphasize at your website. (You do have a website, don’t you?) You then develop material that provides information for people in your area of interest.
When a parent happens into your website, she sees your offer of a free report on “Why Some Kids Get Picked On by Bullies.” This parent doesn’t know you, doesn’t necessarily feel the need to put her child in therapy, and isn’t ready to shell out lots of money for treatment; but since her child is being picked on in school, she’s drawn to your report—and besides, it’s free.
She signs up, leaving her e-mail and/or mailing address, and gets the report. You, in turn, get the opportunity to convert a chance visitor to a new customer or client by gradually taking her through different levels of interest, commitment, and expense.
This vital first step is known as “pink-spoon marketing,” referring to the free samples of ice cream that shops promoting new flavors provide in tiny pink spoons. Customers may like a free sample so much that they buy a cone to consume on the spot or a half-gallon to take home. Similarly, once your customer has her “pink spoonful” and you have her contact information, you can follow up by sending her a newsletter. Most important, you can introduce her to the first of several levels of products along an increasing price continuum.
Once someone has obtained, and liked, your free item, it’s quite easy for her to decide to buy your 30-page e-book, “Teach Your Child to Stop Bullies in Their Tracks,” for $17, or even your $40 one-hour teleseminar. She’s getting the help she needs for her son without having to commit to five in-office sessions for $800 to $1,000. It’s a bargain!
Now, having plunked down the money for the e-book or taken the one-hour teleseminar, she may feel she knows, likes, and trusts you well enough to wade even deeper into the help you have to offer. At level three, she’s moved past the taste-testing phase and is ready
to spend “thinking money” (she’ll think about the purchase before making it) for a $100 CD/DVD set, a $125 half-day workshop, or a $175 six-week e-course.
At the fourth level, $200 to $500, the customer will be ready to spring for your big-ticket items, such as a workbook, six CDs, and follow-up calls. She’s reached what we call the “sweet spot,” the point at which she feels connected to you and your message and regards you as someone who can help her. Or you could team up with a partner and create a full-day workshop. One of you could work with the children and one could work with the parents. This could be marketed locally and on your website. Then you could take the handouts and exercises and create a workbook. Add a lecture on a CD and you have a product to sell online.
Finally, we reach the heights of level five, at which you offer your most valuable commodity: your time. Counseling, coaching, consulting, speaking, and training are usually offered at this level, and people are willing to spend $500 an hour or even $2,000 to $5,000 a day or much more to work with you one-to-one. Because you’ve taken the time to cultivate a strong relationship through the funnel of products you developed, there are multiple possibilities to offer.
In an almost underground manner, some therapists around the world are implementing this Multiple Streams of Income for Therapists model. Some are just getting started and some have been doing it for years. Let’s take a look at a few of them.
Josue Maymi, a therapist in Houston, has been practicing since 1993. He decided that he’d like to create some small booklets with advice on various topics, and has focused on the problems of couples in relationships. He’s written a playful yet insightful booklet, Ten Qualities You Want in a Friend, Lover, Employee & Business Partner and Twenty-One That You Don’t Want, which he sells on his website, www.menarestupidwomenarecrazy.com. “I have a lot more ideas for products,” he said. “This is very exciting to see how I can sell information products on my website and help a lot of people that might not even be in my area.”
Esther Kane, a counselor in British Columbia, Canada, offers books on relationships for women. She has a special affinity for those with eating disorders and has created six audio recordings that can be purchased and downloaded on to her site: www.endyoureatingdisorder.com. For $19.95, clients can purchase audio recordings on such topics as “Mindful Eating.” These can be downloaded to an mp3 player and listened to anytime.
Belleruth Naparstek, a licensed social worker in Cleveland, is the author of Invisible Heroes: Survivors of Trauma & How They Heal. In 1988, she had a robust practice, so she wasn’t looking for a way to make more money; however, to meet the needs of a client who was undergoing chemotherapy, she made a guided-imagery tape. The tape was a hit. Not only did it help the client, but a waiting-room nurse in the hospital began requesting copies to use with other patients. Intrigued that an audiotape could provide such results, Naparstek started creating more tapes.
For years, she kept her practice while developing guided-imagery tapes for people struggling with different diagnoses. Then she decided to turn this process into a business. “I recognized that I was only going to help so many people with my practice, but with these tapes, I could help a lot of people, and I wouldn’t even have to be there.” Naparstek and a business partner persuaded Time Warner to publish the tapes, and have since created www.healthjourneys.com, a portal that posts research and practice articles, and offers scores of tapes, CDs, videos, and software. The site has a growing list of titles by other practitioners that promote not just guided imagery, but meditation, yoga, qigong, acupressure, and a host of other research-supported, mind-body methods.
“I love the autonomy and creativity that this business provides me. But it isn’t just that,” Naparstek reports. “Studies at Duke University are now showing that for PTSD, guided imagery, delivered via an audio download, leads to outcomes that are as good as or better than interventions with cognitive-behavioral therapy, and better than supportive therapy. This isn’t just an alternative to Ôregular therapy’: it’s a portable, scaleable, affordable, self-administered product that works. And at a time when other businesses are struggling, ours is doing well, because we provide an inexpensive group of resources for stress.”
While Belleruth Naparstek fell into the Multiple Streams of Income for Therapists model, Bill O’Hanlon specifically chose it. He saw the power of Internet technology and recognized that it could be a way to deliver content to people who were searching for information. Excited about this medium, he loved the challenge of creating products and services that would help people and be a “passive-revenue” stream for him. “This allows me to reach a much wider audience than I could have in my clinical practice,” he notes.
O’Hanlon, an author of more than 29 books, offers dozens of free and for-fee information via websites, podcasts, blogs, web-based courses, teleclasses, and audio and video programs. “At this point, I don’t do any clinical work,” he reports, “only writing, speaking, a little phone coaching, and lots of Internet-based stuff: e-books, online courses, digital audio and video, et cetera. I love what I do, and work way less than I used to, so I now have a life instead of just work with a little life on the side.”
When visiting his site, www.billohanlon.com, people can get a variety of free items and purchase an array of products as well. For example, a web visitor can buy A Lazy Man’s Guide to Success, a $15 e-book. Someone struggling with anxiety or feeling desperate can get Calm Beneath the Waves, a $12 hypnotheapy audio download. He also offers an e-mail membership program called “Change: 101 Email Tips” for $10. Members receive a tip every four days to help them “get off the dime” and make positive changes in their lives. O’Hanlon’s in-person contact with clients takes the form of speaking engagements and workshops.
Not everyone chooses to close his or her practice, as Belleruth Naparstek and Bill O’Hanlon did. In 1983, the husband-and-wife team of Ellyn Bader and Peter Pearson opened The Couples Institute in Menlo Park, California. Since then, they’ve expanded and added additional therapists to their institute, allowing them to serve more people. But over the years, their experience with couples taught them that people want to learn how to improve their relationships in many ways besides sitting in a room with a therapist. Via their website, www.couplesinstitute.com, Bader and Pearson now offer books, audio recordings, and membership programs for therapists and couples, but they continue to see couples in their offices in traditional one-to-one counseling sessions.
Providing additional, affordable resources for couples is a win-win situation for the Couples Institute and the couples it serves.
All these clinicians have been using the Multiple Streams of Income for Therapists model for years. Their businesses are highly successful today, but they all started with that first product, like Naparstek’s initial audiotape. Our current social and economic conditions are calling to us to provide alternate solutions. Therapists are uniquely trained and qualified to provide the educational materials that society wants today. You don’t have to be a Dr. Phil or John Gray to do it. It just takes the courage to take the first step: to look at a potential market and think, “What do I most want to share with them?”
Sadly, many private practices won’t survive this economic turndown. The challenge for therapists is to respond to the social and economic climate with a model that works: the Multiple Streams of Income for Therapists. It allows us to respond appropriately to important cultural changes and stay in business, making both money and meaning.
Building our practices on the basis of seeing one client per hour worked well when the psychotherapy field was growing, but it has become a root-bound approach. We need to expand our thinking and find a bigger, more capacious model—one encompassing new ways of thinking about how we work and deliver our services to those who need them. Simply put, we need a bigger pot.
Casey Truffo, MFT, is the CEO and founder of the Therapist Leadership Institute and a marketing coach and owner of Be a Wealthy Therapist, where she offers free audios, articles, and tele-classes to help therapists market their private practices and enhance the lives, careers, and reputations. Her self-study course, available on the site, is Pink Spoon Marketing for Therapists.