Shopping For Therapy


Yesterday’s Patients Are Today’s Educated Consumers

September/October 2013


The expectation of a full caseload of long-term clients who don’t question the length or expense of treatment belongs to a former age. Like it or not, therapists who wish to stay in business need to grasp the difference between the patients of yesterday and the educated mental health consumers of today.

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.

Sure, the public at large—never fully on board with the need for mental health services—mostly stayed away, so the market for therapy was limited, but for people who sought out their services, therapists held a distinct and elevated role. They were still viewed as experts on the obscure inner workings of the psyche and assumed something like the authority and gravitas of priests. They unquestionably wielded the power in the therapeutic relationship, while the clients—or patients as they were universally called then—were the seekers, the pilgrims. After all, the therapists were guides through the murky landscape of the unconscious, keeping patients on track when they inevitably stumbled and got lost in the land of unresolved drives, family-of-origin issues, and transference. Their job was to lead patients through the dark, mysterious realm of the psyche and back out into the light toward insight, reason, self-knowledge, and emotional maturity.

Therapy wasn’t supposed to be fun, or even pleasurable. It was serious, life-changing work, drawing on the deepest elements of the human heart and mind, and good therapists didn’t make sessions easy for patients. In my early training as a psychodynamic social worker, it was hammered into me that less was more, and a blank face was necessary so my patient, through the power of transference, could assign to me a shifting cast of projected identities, playing out his or her own complicated inner drama. I offered clinical interpretations, but was cautioned to do little explaining of what was supposed to happen in therapy, not to mention how long it might take for anything to happen. Teaching, coaching, instructing, advising—any active verbs besides listening and asking—were frowned upon. It wasn’t my job to grease the wheels of the session with small talk or ease my patient’s discomfort.

Amazingly, most patients seemed to accept the challenge of working with me, despite the ambiguity and sometimes mystifying ritual of the weekly or biweekly therapy appointments. Those who asked to know my track record, who insisted on telling me what they wanted out of therapy, who tried to put limits on the length of treatment or haggled with me over fees, were seen by me (and by my supervisor and teachers) as caught in the scramble of their own resistance. Of course, it was hard, expensive, and time-consuming to be in therapy, but we therapists and our patients had a sense of being privy to a secret tool, a demanding yet rewarding process for living the well-examined life.

Nearly all therapists underwent the pilgrimage of therapy as well. In my first years in practice, I met only one working therapist who’d never been through individual therapy herself. She was in my peer-supervision group, and I was shocked that she’d be in the profession without having experienced what she was asking of her clients. Everyone else I’d met in graduate school, training classes, workshops, and other supervisory settings had spent long years and thousands of dollars in school, learning the craft of therapy and working on themselves. But we expected the road to be demanding. This was our apprenticeship. Being a therapist was a vocation, a calling, much more so than an occupation. The colleagues I knew felt transformed by their own therapy and called to provide comfort, guidance, relief, even healing to others experiencing the often excruciating, sometimes life-threatening, emotional anguish of being human in inhuman times.

Perhaps the status and authority afforded to therapy in that bygone era owed a good deal to its being such a unique creature, neither art nor science. In a democratic, popular culture, its hierarchical nature, monastic characteristics, and refusal to sell itself—at least overtly—allowed it to float, somewhat majestically, outside the social norms of the time. Like most attorneys and doctors, therapists like me didn’t think of what we offered as a product or a commodity: we were offering life-change. My early colleagues and I shied away from the language of promotion, marketing, self-branding, and profit maximization—activities considered ill-disposed to the sanctity of the therapeutic enterprise.

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.

The biggest reason for the ongoing economic recession for therapists is the encroachment of managed-care insurance, which has become the driving economic force in medical practice. A study from the American Journal of Psychiatry in 2007 shows how the for-profit insurance industry dealt the major blows to therapists with the triple threat of their cost-cutting measures: a decline in the frequency of allowed sessions and a preference for advocating medication over talk therapy, resulting in a steady decline in fee-for-therapy sessions.

As if the change in earnings these measures brought about weren’t hard enough, competition to be in private practice to find clients has become increasingly fierce. According to former American Psychological Association president Nicholas Cummings, one of the field’s most accurate prognosticators of market trends for nearly 60 years, there’s now a massive oversupply of private practitioners: estimates of the number of masters-level therapists in the United States average about 600,000. Also, the costs of running a practice haven’t gone down, so therapists still need to pay high rents and other fees. For some industries, the challenges of a changing market are seen as a basic business 101. But having little formal education in business, the average therapist in private practice is facing hard times and is vulnerable to these multiple pressures.

This isn’t to say that most therapists don’t see the handwriting on the wall. Many have stayed current with the changing economic trends and are trying to make a go of it, but often in their own haphazard way. They know they have to do something. They just don’t know what exactly to do, or when or how to do it, or even if they want to. 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 Good News

The good news is that therapists in private practice are determined to find ways to stay afloat, and many are eager to adapt. Those who are sufficiently stout of heart and open to the challenge of learning the business and marketing principles of successful 21st-century practice will find that they can not only learn these new skills, but also excel at them. I’ve seen many therapists who insisted that they’d never be good at business come to enjoy being proficient businesspeople and making more money in a streamlined, organized practice, which enhances their ability to do their best work.

Despite all the factors undermining our earning potential as therapists, the market for our services is poised to grow. The Centers for Disease Control estimate that around 25 percent of adults experience a mental health issue in a given year, and 50 percent of Americans will experience some mental health issues over their lifetimes. So it’s fortunate that the Affordable Care Act will provide one of the largest expansions of mental health and substance-use disorder coverage in a generation, with an additional 32 million people receiving coverage. Additionally, crass as they may seem to therapeutic traditionalists, media shows like Dr. Phil, Celebrity Rehab, and Oprah have pulled therapy out of the societal fringe and into popular culture, making it less taboo, less mysterious, and ultimately more acceptable.

Thanks to the Internet, therapy is now increasingly accessible, too. Google can find a therapist in any zip code in just a few clicks, opening doors for potential clients seeking therapists and leveling the playing field for therapists seeking clients. With minimal expense, any therapist can achieve online visibility, and many of the ones I work with as a business coach report that upwards of 50 percent of all new clients are finding them online.

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.

Harriet, a marriage and family therapist in Chicago, knew that she needed to advertise her private practice and was told that having an Internet presence was an important first step. So she hired a designer to build her an attractive site and listed her practice in Psychology Today’s online directory. Sure enough, clients found her and called to book sessions. But that’s when her trouble started.

“I’m getting discouraged with the new clients who find me on the Internet,” Harriet told me in our first practice-building coaching session. “I can’t seem to satisfy them, and, frankly, they intimidate me. They want to negotiate everything up front during the first phone call, while I’m still trying to connect and understand their issues. They tell me when they want to be seen, instead of asking how I work. They don’t get how therapy is supposed to proceed. And if I can’t ‘fix’ their problem in the first session, they’re reluctant to come back. I’ve been a therapist for almost 20 years, and I’m confident that I know what I’m doing, but these new clients have a way of making me feel insecure and incompetent.”

Harriet’s concerns aren’t just the grumblings of a burned-out therapist: they’re the result of a trend that began several years ago, when an increasing number of clinicians, both new and experienced, started advertising their practices online. As a business coach who works with therapists across the country on all aspects of practice building, I regularly hear them complain about this new type of client they’ve started attracting—one that’s hard for them to relate to and retain.

These clients shop for therapy much as they would for any online product: by comparing, contrasting, and learning as they go. They’re often young, anxious, and used to immediate gratification. And they have no compunction about treating a therapist in the same way they would any other service provider—after all, it’s their time and money. Before booking a session, they negotiate fees or challenge normal established policies they don’t understand, such as weekly sessions and cancellation policies. They want a timeline for results within the first session and get impatient about a lack of immediate progress. Harriet, like many therapists, was frustrated with this consumer-oriented client, while knowing full well that the future of her practice depended on her ability to market to them.

I first heard the term educated consumer in the 1970s, when retail clothing tycoon Sy Syms advertised “An educated consumer is our best customer,” suggesting that sophisticated consumers who understood fashion and discount pricing would prefer his clothing stores. In working with therapists to build their practices, I’ve started calling this new type of client they’re facing educated consumers, or ECs for short. This term helps therapists better understand clients who, despite a lack of education about the methods or history of therapy, possess a deep knowledge about finding and purchasing what they want. In the past, the goodwill and trust inherent in the old referral process used to overcome clients’ need to have a concrete understanding of the therapy process before diving in; today, however, the marketing of therapy relies less on well-placed referrals and more on online presence and visibility, so therapists need to recognize that their website text and design, online photo, and voicemail message educate potential clients, as shoppers, about what to expect. When a therapist is too vague in a website description of services available, or suggests results without explaining all the steps and variables ahead of time, ECs feel skeptical and won’t hesitate to express their irritation and reservations.

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.

Setting Expectations

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 ECs 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 EC parents posed, he was relieved that he now had more effective ways to answer them.

Making Value Visible

Sue, a clinical social worker, was weary of educating new clients during the first phone call. “It’s discouraging that I have to sell the idea of therapy or counseling and explain why it even works,” she said. “From session to session, they don’t see the big picture of how therapy can change their lives in major ways.”

As I coached Sue to help her clients see the value of her services, she decided to try leaving 10 minutes at the end of each session for a review. During the review, she first asked a client to share what he or she thought was of value in the session. Then she offered her own observations, such as “When you talked about your mother, you started to tear up. I know you said you don’t express affection easily, but you showed some in here. That’s progress, and it moves us one step closer to your goal of better communicating your feelings to others.”

This technique allowed Sue to track and validate their progress, which in turn gave clients a firmer sense of the value of sessions and a way to justify the effort and expense of therapy. Although it was a successful method, Sue hadn’t been trained to summarize each session with clients in this way. She needed coaching and role-playing to learn to observe and comment out loud—in essence, to say what she’d normally write in her notes. Together, we shared examples of people who did this publicly with good results. During this process, we came upon one of my favorite behavioral experts, Cesar Milan, the TV “dog whisperer.” He watches for micro movements toward better behavior in the dogs he trains. He then offers immediate reinforcement to the dog and comments on his actions in real time to the owner holding the leash (and the audience at home).

In an episode of the show that fascinated me, the owners, both avid runners, wanted their dog to go jogging with them on a leash in the park. Most dogs love this activity, but not the owner’s Labrador retriever, who hated leaving the house. Milan said that, rather than fixating on the larger outcome of getting the dog to go jogging, the first goal needed to be small—just getting the dog out the door. Although it was tedious work, each time the dog made a small movement toward the door, conscious or not, Milan praised it, explaining each step of what he was doing to the owners. There were backslides and much whimpering on the part of the dog, but within 30 minutes, the dog walked proudly out the door on his leash. Getting to the park and running could take much longer, Milan said, but getting out the door was the critical start.

When Sue heard this story, she told me about a new EC, a young woman in an unhappy marriage, whose stated goal was to separate from her husband. After two months, in which no action had occurred, the client questioned whether therapy was working, and Sue, frustrated about the client’s lack of progress, silently wondered the same thing. Reflecting on the dog-whisperer story, however, Sue realized she needed to start with a smaller goal, one that both she and the client could succeed at and debrief on, marking increments of progress in every session.

Sue reported back that in future sessions, the client was making gains with small goals that could prepare her for separation—getting her finances in order, beginning to reach out to old friends, taking an evening yoga class to connect with a sense of peace. With each step forward, Sue was able to remark on her progress, validate the effort it required, and set small next steps to keep her
client moving forward. Both Sue and the client felt that therapy was now progressing well with this slower, more deliberate approach to defining progress.

Retaining the EC

As we learned above, Harriet, the family therapist from Chicago, was perplexed and discouraged by her inability to retain the younger clients who were shopping for her services via her website. She was glad that they were finding her and booking sessions, but was distressed at their presumptions about the therapeutic process. “They’re impatient and not emotionally aware,” she said. “They don’t understand that sometimes issues get messy before they get better. Just yesterday, after I worked with two parents and a defiant teenager in a pretty intense session that I thought went well, the father said, ‘I’m out of here. If I wanted to argue with my daughter and wife, I’d have stayed home.’ I tried to explain that this was part of the process, that not every session will end with happy faces, but he wasn’t convinced.”

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 ECs, retention needs to be discussed early on in the purchasing process. ECs 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?

In Harriet’s case, I asked her to find an easy-to-understand metaphor or analogy to give her new clients a frame of reference for how therapy works in the consulting room. An avid hiker, Harriet 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.

To prepare for the next session with the father of the defiant teen who didn’t want to come back, I asked Harriet, “Can you give him a clear and concrete reason to stay, one that would be more important than his reason to leave?”

Since Harriet wasn’t used to having to address clients’ tough objections so directly, we practiced what she might say and how to talk honestly and openly about each issue the father had raised. When the family came in the following week, Harriet started by saying that she knew that therapy was an effort and an expense and that they needed to measure progress. Dad jumped in saying “It’s cost me $320 to be here so far, plus four afternoons of leaving work early. And that’s not all. I have to listen to my wife at home criticizing me by saying, ‘Harriet says you’re supposed to do this,’ or ‘Harriet says don’t do that.’”

Some therapists might have been intimidated by his anger, but because Harriet and I had been discussing ECs and their purchasing-driven patterns, she simply said, “I know this is really costing a lot and it’s hard to stick with, so I want you to feel that you’re getting a return on this investment. Let me be straight with you about what’s in store for your family. I think you and your family will need to see me for two more months in order for things to calm down a bit more with your daughter and for all of you to learn the steps needed to resolve issues as parents with her at home. What would make it worth your while to stay?”

“I need to know that it’s working,” he said.

Again, Harriet immediately validated this need, and together they set up specific markers, based on small goals that seemed reachable over two months, to help him feel assured that the therapy was moving forward. At the end of the session, the father said that the most important part of it for him was that Harriet understood how important his time, money, and effort were. He appreciated her being straight with him. He liked the clear idea she gave him of what to do next. He took notes, with Harriet’s encouragement, so that he would remember what was said without prompting from his wife. “He took ownership of the therapy,” Harriet said. But what also changed was that Harriet took responsibility as a business owner and service provider to address issues of money, expectations, and potential results, with clarity and candor.

Making the Shift

As a therapist in my own private practice, and thus a businessperson like the therapists I coach, I’ve had to learn the strategies and skills I describe, too. I admit that I’m not always successful with ECs, in part, because—even with all my business experience—I still sometimes miss practicing therapy the old-fashioned way. I liked doing long-term therapy the way I was trained to do it, and at times, I yearn for those committed clients, many of them veterans of past therapy, who already “got it” in their first session with me. But to make a living as a therapist, I’ve had to teach myself to shift gears and embrace the ECs just as they are: people who conduct an Internet search for the kind of therapist they want and then call for an appointment. I’ve also had to learn that these clients are often facing much harder odds than the typical “patient” of the past, who—despite personal problems—most likely had a solid income, good insurance, and reliable prospects for the future.

Most of the online shoppers who find their way to me are younger than I am, challenged by an unstable society, slippery cultural mores, uncertain careers, insecure jobs, and a stagnant economy. Many are not yet in solid marriages, or even firm relationships, nor are they homeowners. They seem in flux, and those in their twenties exhibit what might look like a sense of overweening entitlement and opinions. They come into therapy with the traditional presenting problems of anxiety, depression, and unhappy relationships, but they haven’t yet, even as adults, developed a secure sense of self. They need clinical holding from the first hello.

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. I call this willingness to be flexible my revolving-door policy—which means telling clients up front that if they need to interrupt treatment because of finances, work, or family demands, they can focus on an issue for a while with me, leave when they want to without any shame or blame (I will never say the word resistance to them), and return and pick up the work when they’re ready, knowing that I’ll be glad to see them again. Using this approach, I’ve maintained consistent therapeutic relationships—although of an often on-again, off-again kind—with ECs for years. Paradoxically, it’s by bending that I make myself a constant, stable factor in the otherwise volatile, insecure world they inhabit.

Recently, I received an email from a potential client, Sherry, who’d found my website and liked the way I explained my services: individual therapy with a coaching approach. We spoke briefly on the phone. She was 26 years old and in graduate school, with few financial resources. She was depressed and anxious, and said she was “shopping for therapists,” so I immediately shifted into EC mode and proposed that she come in for a single session. I have a fee-for-service practice and knew that even a single session would be a considerable expense for her, so I felt some pressure at the start to make the session count. In this session, Sherry had trouble organizing herself. She said she had so much to say and didn’t know where to start. In the past, as a more traditional therapist, I’d have met this statement with silence and a receptive but neutral expression, letting her find her own way into the conversation. This time, however, I asked if she wanted help figuring out where to focus. She nodded eagerly, so I asked her to start by telling me what concerned her the most right now.

I knew that taking this approach meant that I was eliminating some of the unconscious resonance that a blank or neutral nonresponse would have evoked, but since I might have only one session with her, I opted in favor of helping her find something to take away, some small signs of progress I could summarize for her at the end. Although she’d have readily gone in many other directions, I kept her focused on the presenting issue, which was her severe doubt that she’d be able to finish her semester because of her depression and lassitude. At the end, I framed the 10-minute debrief by saying that I wanted to take a short time to hear how she felt about meeting me and our session, so we could discuss what to do next.

“You seem nice enough,” she said, “but I have so much on my mind. I still feel loaded with issues, and I’m not sure how this will help.”

In the past, I’d have heard this statement as part of an unconscious contract for future work to unpack her concerns further. Instead, I stayed with my plan with ECs. “May I share with you what I thought we did here today?” I asked. “We talked primarily about the problem you came in with, how to finish out your semester despite your feelings of sadness and fatigue. We talked about two steps you can take this week: calling your best friend for support and getting out of bed earlier to take a walk before classes. You only need to go step by step this week. We also began to look at some of the other reasons for your sadness. But it’ll take more time to know all the reasons. Based on what we did today, I think you now have some immediate steps you can take to help you feel more in control, if you want.”

Sherry thought about this summary and nodded. “I get it,” she said. “You’re right, that’s what we did. Good.” Then, realizing she was still in shopping mode, she asked to come back one more time. By the following session, she was fully on board for weekly therapy. She told me she’d heard my voice inside her head all week, calming her down, reminding her just to take the next step. She became a hard-working client, who, even after taking a break over the summer to travel, came back in the fall to resume our work.

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Do the needs and expectations of ECs like Sherry 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.

In today’s economic climate—with a stubbornly high unemployment rate, the potential for another recession, and the unpredictable swings of the health-insurance industry—uncertainty is the common lot of small business owners, including therapists in private practice. We can’t individually or even collectively do much to control the future, economic or otherwise. But, as Neurolinguistic Programming founder John Grinder once said, the most flexible participant in a system will have the most influence or choice in that system. During a negotiation, for example, the person with greater flexibility—who can see and understand the point of view of the other side and adopt multiple strategies for resolving disagreements—is likelier to bring both sides to a win-win resolution than the person who stubbornly refuses to budge from one rigidly held position. 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.

Lynn Grodzki, LCSW, MCC (Master Certified Coach), is a therapist in private practice and a business coach for therapists and other helping professionals. Her latest book is Crisis-Proof Your Practice: How to Survive and Thrive in an Uncertain Economy. Contact: lynn@privatepracticesuccess.com website: privatepracticesuccess.com.

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5 Comments

Wednesday, September 11, 2013 6:17:16 PM | posted by Jennifer Knight
Excellent, helpful article. Thanks for articulating the obstacles to building a private practice and practical tools for how to address them and to turn each obstacle into an opportunity for providing better service.

Thursday, September 19, 2013 6:57:40 PM | posted by Sally Palaian
Thanks for the great coverage about the business of therapy in the modern day! Psychotherapy Networker is always on the cutting edge with timely issues for clinicians. All three articles articulated exactly what I’ve been feeling lately with my practice.

As a follow-up to Lynn Grodzki’s article on the new educated consumer, I have one additional comment regarding new couples expecting that we bill their insurance for Marriage Counseling.

It’s ironic that people somehow have enough money to spend when they plan their wedding and honeymoon.
They also find enough money to pay for lawyers when they are done with their partner and seek out divorce.
But, somehow marriage counseling is too expensive for them, and they perceive that they can’t afford it, and must use their health insurance.

From what I understand this is insurance fraud when clinicians write up conjoint sessions when really it was marriage counseling. I don’t have a large practice but I have turned away 15 couples in the last three months; all insisting that I should bill their insurance for payment. (Including one health insurance executive, no less!) I am sure they found another clinician who was indeed willing to submit the bill to the insurance company and “write it up” in such a way that the insurances will pay.

Marriage counseling is hard work, I’m not willing to do fraudulent things and jeopardize my license and career for total strangers. Nor am I willing to be bullied into accepting the lower “insurance” rate as payment. I am sad for our profession because so many clinicians believe the florist and the bakery deserve to get full fees, but we do not.

Sunday, October 6, 2013 5:14:17 PM | posted by theodora McDowell
I am in Private Practice and I found this article extremely helpful. It addressed so many of the issues I have been seeing with clients today, and gave me concrete ways to change my approach to meet the needs of today's consumers. It was Fantastic!

Saturday, August 16, 2014 5:15:29 PM | posted by Mary Mattis
Lynn Grodzki is generous with her practice building information. Making this article assigned reading for the people I supervise. Very useful tips, and actionable too. Thanks for the article!

Wednesday, February 17, 2016 10:37:00 AM | posted by Caryn
That was a fantastic article. It addressed many of my questions, professional struggles and concerns, and brought to light many that I was unaware of. Thank You

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