From the March/April 1994 issue
ALL THROUGH THE 1980s, THE phone kept ringing and the money rolled in. Like many of his colleagues with established reputations, a psychotherapist we’ll call David Cornfield had more than enough clients. He did high-impact, short-term work with families and individuals, and whenever clients left, others called to take their place. He charged what the market would bear as much as $200 a session and earned more than $200,000 a year. His practice took care of itself. Then, in 1990, with a confidence that now looks like hubris, he took a sabbatical to live in the country, rethink his life, work with low-income families and train other therapists. He came back two years later like a figure in a fairy tale who has stayed too long at the fair.
Cornfield found a new office and called old clients and friends. The phone rang a few times. A few new clients came, but his calendar had long blank spaces. He called established therapists and asked for referrals. Nothing happened. “My practice just hung there at about 15 people a week, going up to 20 and then down again,” he says. This year, he earned a third of what he earned in 1990.
While Cornfield was away, a few large managed care companies and health maintenance organizations had come to dominate the Boston health-care market. No longer did employer-sponsored insurance programs freely hand out $3,000 a year for therapy, with few questions asked. Managed care companies now paid the bills, and they had signed up panels of therapists to work at a discount panels that were now closed. To make things worse, the economy had tightened, there was a glut of therapists, and fewer people had the cash to pay for therapy out of their own pockets.
Cornfield’s phone continued to ring only sporadically. Last year, confused and embarrassed, he turned to Linda Lawless, a marriage and family counselor and a marketing consultant one of dozens of marketers who help anxious therapists negotiate the rapids of a changing economic world Many of them, including Lawless, are former psychiatric nurses, experienced in dealing with big bureaucracies. Their therapist-clients, like Cornfield, on the other hand, have spent their lives working for themselves like village shoemakers who once sewed shoes to fit each patron’s foot. They quietly built reputations; their work spoke for itself. They didn’t have to clearly define what they did or promote it aggressively to executives carrying briefcases and wearing suits. Somewhat bewildered, they have turned to marketers to help them negotiate the transition from craftsperson to “provider,” and to draw the attention of the distant conglomerates who now pay the bills and funnel the clients. In a few brief years, everything has changed in this profession, and in the future, the marketers say, it will change even more.
Lawless advised Cornfield to begin with the basics. As she does with all new clients, she helped him identify what he does best, establish a specialty, get a clear, well-designed business card, and get his name out into the community. She recommends her clients go to conferences and join chambers of commerce, shake hands, talk to community groups, give free workshops in schools, run low-priced, introductory therapy groups and weekend workshops, and teach adult education classes.
In the old days, that was enough to prime the pump and introduce personable, qualified therapists to a geometrically increasing base of potential clients. But today, the real “customers” are managed care executives, not individuals. Therapists can no longer rely on the kind of promotion that works well in a village atmosphere. The managed care companies are corporate bureaucracies with their own needs; they demand different skills of therapists than individual clients do, and they require a marketing strategy all their own.
Even to get a foot in the door with them requires a familiarity with the tools of rapid business communication. “Many therapists are computer illiterate,” says a leader in a company that runs weekend seminars for therapists who want to get involved with managed care. “Fax machines mean instant treatment authorizations, and some of the bigger managed care companies will be cutting their paperwork by linking up to thousands of providers by modem. But these therapists don’t have fax machines; they don’t have computers. Sometimes 1 wonder why are they even trying?”
Once the fax machine is installed, therapists should find out which managed care companies represent major local employers and concentrate on them, recommends Tamara Cagney, another former psychiatric nurse and director of marketing for Behavioral Health Quest, a group mental health practice in Pleasan-ton, California. Sending in a resume is not enough. “You have to call and tell them about your specialty,” Cagney says. “If you’re multicultural, that’s a plus, and you should send in a picture if you don’t have a readily identifiable ethnic surname.”
Making yourself stand out with a specialty, the marketers say, is the key to survival, because managed care companies are too big to sort through their rolodexes otherwise. “People who say they do everything will do nothing in the future,” says Adam Richmond, a spokesperson for the Institute for Behavioral Health Care in Tiburon, California. “Even when managed care companies say their panels are full, they may still need Hispanic psychiatrists in Los Angeles, or someone who works with anxiety disorders, or gay and lesbian therapists in Des Moines.” Adds Cagney, “Recognize that the people buying your services are the employers and not the clients. They want people who understand workplace issues, and the hot things right now are work with individuals with physical disabilities, violence and threats of violence in the workplace, and sexual harassment.”
The right location helps, too, and 10 miles in the wrong direction can doom even a talented specialist One clinical social worker was first approached by managed care companies 10 years ago partly because of a relative shortage of therapists in downtown Boston, where she has her office even though the nearby suburb of Newton was oversupplied. “Therapists need to see if they’re in an overserved zip code they can just look in the phone book,” advises Adam Richmond. “They may need to open offices in two different outlying suburbs and work in each one a couple of days a week.”
But, in this rapidly changing and competitive market, it’s not enough to do things by the book. Promotion, say the marketers, must be done ingeniously, over and over. “You go bang on the door of managed care and they say, ‘I’m sorry, we’re full, thanks for your call,'” explains Patricia Motz Frazier, a former psychiatric nurse and marketer who runs Marketing Resource Consultant in Mission Viejo, California. “Most clinicians say, ‘Okay, they’re closed,’ and walk away. Closed is never closed. The first ‘No’ is not an answer. You have to keep making them aware of you at appropriate intervals. If they say ‘No’ at the front door, you have to say, ‘Okay, let’s figure out how to get in the back door, and the side door, and the attic window.'”
Among Brazier’s clients, for example, are a dozen therapists in the saturated Los Angeles market who formed a group practice but were turned down by managed care companies whose panels were full. When Frazier learned that the companies needed therapists to serve suburban Apple Valley, her clients recruited some good Apple Valley clinicians into their group and slid onto the panels.
Therapists must also do market research: Will managed care companies pay for the specialties they choose? If not, therapists must repackage and retrofit One woman therapist, for example, specialized in long-term therapy with women who were sexually abused as children. Once managed care hit, her practice declined by 50 percent because the companies didn’t want to pay for long-term work. With Frazier’s help and the collaboration of several managed care companies, the therapist designed an intensive evening outpatient program to help people in crisis stay out of psychiatric hospitals. The clients people facing traumas such as devastating divorces, rape, the suicide of a relative, or the spontaneous recall of childhood sexual abuse could manage during a structured work day, but fell apart at night. So, for seven days, they came to the therapist’s office after work for a catered dinner and an evening therapy program. “Managed care companies went for this program,” says Frazier, “Because it kept people out of the hospital and because they had a hand in its creation.”
Even this kind of individual ingenuity won’t be enough in the future, the marketers say, if managed care companies merge, as predicted, into a few enormous organizations. As this happens, therapists will have to organize at a whole new level, creating group practices big enough to provide one-stop mental health shopping to corporations responsible for tens of thousands of employees.
“In the short term, you have to make sure you’re on the panels. In the longer term, therapists are going to have to create group practices without walls, to join with others in private practice and market themselves as a group,” said Don Patterson, a North Carolina psychiatrist and consultant who founded one of the country’s first and most successful psychiatric group practices.
In group practices, therapists will have to learn to work together and to take on shared economic risks, but they may get back some of the autonomy and control they have lost to managed care companies. In essence, the groups work like this: psychologists, psychiatrists, masters-level counselors and other mental health workers band together and offer a major employer an integrated package of mental health services, including assessment, outpatient therapy, workplace prevention workshops, referrals to self-help groups, medication management, hotlines, outcome studies, 24-hour crisis intervention, psychiatric hospitalization, and intensive substance abuse treatment In Minnesota, for example, 125 psychologists, psychiatrists and clinical nurse specialists, chemical dependency counselors and marriage and family therapists have recently formed QualityCare, Inc. and are negotiating to provide a full spectrum of mental health services to local businesses that employ 10,000 to 80,000 people. “This way, we’ll have some say in how the system is designed, versus some accountant or clerk telling us how to do it,” says Steve Peltier, a psychologist and member of the QualityCare board of directors.
Being part of the group may be enable its members to spend less time on case micro-management and more on doing therapy. Peltier believes that close management of outpatient therapy is not cost-effective unless a client will receive at least 20 sessions, because the review alone typically costs $900 money better spent on therapy. Psychiatric hospitalizations, on the other hand, consume 80 percent of most companies’ mental health budgets, and could be more intensely reviewed, Peltier said.
All of these changes from the simplest self-promotion to the most sophisticated group practices go against the psychological grain of therapists who thought they’d always be able to work quietly, intimately and on their own. Many have not had a boss or worked in a group since shortly after graduate school, and the change is experienced as painful and difficult Selling yourself to a managed care company means adapting to a new role and learning new social skills that graduate schools and seeing clients don’t teach. “Going out to sell yourself to managed care means being able to make them see that you are the best option,” says Patricia Motz Frazier. “Most therapists are not good salesmen. They like to give people a lot of options and to close a deal, you have to narrow the options down until the only option left is to hire you.” Adds Linda Lawless, “They train this kind of promotional instinct out of us in graduate school you’re always supposed to put your clients’ needs before your own.”
And even learning these new skills will not be enough. Whatever national healthcare plan Congress passes will probably produce a new set of working conditions, and a new group of “employers” who need to be sold, once again, on a therapist’s competence. In this period of rapid change, therapists will need what anthropologist Gregory Bateson called second-order learning not simply new skills, but the continual ability to learn new skills.
“We should expect significant continual change rolling change over the next five to seven years,” says Anne Kilguss, chair of the managed care committee for the National Federation of Societies for Clinical Social Work and a licensed clinical social worker with a busy managed care practice in downtown Boston “Every six months, there’ll be a new twist,” Kilguss says. “We have to stay informed, watch what’s going on and be prepared for change. Nobody has a guaranteed income or a fix on life any more. A lot of therapists don’t want to do what we expect our patients to do all the time: adapt to change.”
Katy Butler, a former features editor and staff writer for Psychotherapy Networker, is the author of two award-winning books about aging and living meaningfully in life’s final quarter, especially in relation to modern medicine. Knocking on Heaven’s Door (2013) was a New York Times Bestseller and Notable Book of the Year. The Art of Dying Well (2019) is a road map —practical, medical, and spiritual —through the significant passages of life after 55. Katy’s groundbreaking work for the Networker was nominated for one National Magazine Award and contributed to several other NMA awards and nominations. Her writing has also appeared in the The New Yorker, The New York Times Magazine, Tricycle: the Buddhist Quarterly, Scientific American, Best American Essays, and Best American Science Writing. Other honors include first-place awards from the National Association of Science Writers and the Association of Health Care Journalists; a “Best First Book” award; and a finalist nomination for the Dayton Literary Peace Prize. She lives in northern California and loves to dance in the kitchen to Alexa with her husband Brian.