When I first became a therapist, 25 years ago, long before I became a business coach to other therapists, the field was still at the tail end of the Golden Age of Therapy—or maybe it’d be more accurate to call it the Golden Age for Therapists. Back in those balmy days, therapists could count on handsome insurance reimbursements for seeing clients long term, and were part of the same cozy referral system as their medical colleagues. They generally didn’t have to worry about filling empty appointment hours or constantly trolling for new customers. In fact, most therapists considered themselves above that sort of thing. To start up a practice, you simply hung out a shingle or printed a business card, told a few key colleagues you had hours to fill, and waited until clients arrived at your door.
To most of today’s younger practitioners, this Golden Age for Therapists seems like an idyllic fairy tale, replaced by an era that might be called the Aluminum Age to reflect the less precious, more utilitarian perception of therapy by the public and our profession itself. No longer seen as elite healers, therapists are now commonplace service providers of healthcare. The devaluing of therapy has made it more accessible to the public—something most would agree is a good thing—but has created a precipitous change in the way therapy is valued and delivered. Indeed, the economics of psychotherapy and, particularly, private practice have never been so challenging or dire. For private practitioners, the economic recession started not in 2007, but in the late 1990s. Factoring in inflation, therapists today are earning only a third of what they were 10 or 15 years ago.
Even when therapists learn some marketing strategies or attend a business class, they often feel like fish out of water. Many recoil from what they’re being told they must do to survive: promote themselves and their services.
Does this mean therapists ought to throw in the towel and go into another line of work entirely? No. As I tell the hundreds of therapists I meet with and coach in their businesses each year, it is possible for them to do good, satisfying, genuinely healing work, hold onto their ethics, and get paid regularly and fairly for what they do. But to accomplish these things, they have to change the way they approach their practice. The belief that they can fill a practice with long-term clients who come to sessions each week and don’t question the length or expense of treatment probably belongs to a former age. They need to understand the changes in technology that are bringing in new types of clients with different expectations and needs. And, like it or not, they’ll have to become comfortable with the idea of joining the ranks of other entrepreneurs and implementing solid business planning and marketing.
The New Breed of Client
While online accessibility allows therapists to get found, the people who find them represent a kind of client different from the ones who used to come through referrals from doctors or trusted friends. This new kind of client can search multiple listing at a time, rapidly book and cancel their appointments on the web, and rate their therapists online with starred reviews. In general, they act less like patients willing to assume the traditional role within the therapeutic model and more like Walmart shoppers scanning the aisles while checking their mobile phones for better deals. In turn, therapists are waking up to the reality that relating to online shoppers for therapy services requires new skills.
Fortunately, if they’re willing, therapists can easily learn to articulate services more effectively in ordinary language, help potential clients understand services within their preferred framework of purchasing, highlight and concretize the value of therapy, measure and articulate progress within each session, and use strategies to help clients stay long enough for them to see a clear return on their investment.
When I began working with Jonathan, a child psychologist for learning-disabled children, he said, “Most of the parents of the children I see find me on the Psychology Today site. They email or call and immediately ask how many sessions it’ll take to fix their child. I try to explain that I have to test the child, assess the results, and then determine a treatment plan, but they’re impatient. They have no idea that part of the ongoing work involves more than teaching neurofeedback skills and applying other tools. I also have to forge a relationship, which takes time.”
It’s normal and natural for educated consumers to want to feel in control of what they’re purchasing from a therapist, so it’s obvious why they insist on knowing exactly what to expect in a session and how long it’ll take. The fact that therapists aren’t comfortable predicting these outcomes doesn’t make it less important to give answers.
I wanted Jonathan not only to be prepared to answer questions from parents openly and clearly, but also to give parents a systematic way to understand his services. His existing contract for new clients was a standard one that many therapists use, outlining policies about confidentiality, procedures for payment, how he deals with cancellations and missed sessions, and informed consent about HIPAA compliance. But there was nothing in his contract to give his clients an immediate sense of what’s available, what to expect, and why to expect it. Thus, I suggested he add a section, specific to his clinical services, that used the idea of packaging.
First, Jonathan needed to do some research about his own practice. I asked him to look through his client data to understand his natural patterns of providing services. In doing so, he saw that over the past two years, he’d spent an average of six months working with each child. He checked his notes to see what he did with the children month by month. Dividing the time into thirds, we then created a package made up of three stages, and named each two-month stage, defining its purpose in easily understood terms.
When the next new parents emailed or called to ask about his services, Jonathan was ready. He could now explain to them that in the first stage—Training and Testing—he’d use neurological feedback to help the child stay calmer when learning. In the next two-month stage—Creative Problem Solving—he’d give the child a variety of tools to use at school and home to resolve frustrations. The final phase—Consolidation—would help the child refine the skills needed to keep learning on track. In the end, he could clearly tell them, “That’s six months for a full program of testing, training, problem solving, and strengthening.” If children needed more sessions or time, Jonathan would recontract with the parents for a longer period of one of the three stages. With this contract in place, Jonathan found it much easier to engage new parents, set expectations, and help them connect to him and to his process of therapy for their child. Instead of fearing the inevitable questions these parents posed, he was relieved that he now had more effective ways to answer them.
Retaining the Educated Consumer
Since part of our role as therapists is to encourage clients to stay in therapy long enough to complete their work, it’s hard to watch treatment be cut short, not only because we’re invested in our clients and want them to heal, but also because—let’s face it—we need to make a monthly income. For this reason, talking about client retention is both a clinical and a business issue. When working with educated consumers, retention needs to be discussed early on in the purchasing process. These clients want to understand how to get their money’s worth, and that means a therapist must explain the concept of sticking with treatment for a certain amount of time, even when it feels uncomfortable.
A stockbroker might talk with a new investor about the need to stay in the market long enough to see a profit, despite inevitable ups and downs. A gardener might talk about the need to be patient with seedlings planted in new soil. A personal trainer might explain the need to endure discomfort with a strength-training routine before seeing new muscles emerge. But how does a therapist start this conversation?
I ask many therapists to find an easy-to-understand metaphor or analogy to give their new clients a frame of reference for how therapy works in the consulting room. An avid hiker, one therapist liked the idea of relating therapy to climbing a mountain. Although you can’t see the view at every step, you need to trust the path and the guide until you can get to a clearing, look back to see progress, and imagine the end point. We role-played how to build on this metaphor with clients, and she added a picture of a mountain path to the artwork in her office, which gave her new clients a visual reference to understand the therapy process and their own path in any given session.
Making the Shift
Other therapists I talk to have shared that they’re seeing not only more anxiety in new clients, but more crises. Clients are waiting longer to come into therapy because of its cost, in time and money. When they arrive, they have a bundle of complicated issues and are looking for immediate relief, as well as a sense of security, support, and belonging. For these clients, I provide more structure in a session and make the process of therapy transparent. I explain what I’m doing out loud as I do it, set measurable goals, validate all advancement, debrief on any and all progress at the end of each session, and emphasize my flexibility in meeting their needs.
Do the needs and expectations of these clients signal a paradigm shift in how we need to do therapy? If so, what’s lost, and what’s gained? I know that as a therapist and change-agent, it’s important to be open to change myself, even if it means changing the way I understand what therapy means and what it can offer. In a field like ours, it’s hard to know for sure after only one session what each person will need from therapy. What I do know, however, is that today’s clients need to be their own advocates in all areas of healthcare, to find their own information, to choose from various options, and to assert a level of control that would have seemed foreign to clients during therapy’s golden age. Often the best I can offer is to give them choices about ways I can work with them and let them decide what they think might be best. This has the double benefit of allowing them a sense of agency and control, while giving them an opportunity to make mature decisions, at least about therapy.
We can’t individually or even collectively do much to control the future, economic or otherwise. But just as a small business owner has the advantage over huge corporations in being more capable of flexibility; a private practitioner can quickly change course, adapt to a new market, stop an unprofitable program, start up a needed program, or take on new ways of relating to clients. If you want to dance with the new economy and not get stepped on, you’ve got to be light on your feet, ready to turn—if not on a dime, then at least on a quarter—and master some moves you never imagined yourself performing.
This blog is excerpted from "Shopping for Therapy" by Lynn Grodzki. The full version is available in the September/October 2013 issue, The Selling of Psychotherapy: What Are the Rules in Today's Market?
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Illustration © James Yang
Topic: Business of Therapy
Tags: business | Business of Therapy | Lynn Grodzki | marketing | marketing private practice | marketing psychotherapy | private practice marketing | psychotherapy business | therapy business | therapy marketing