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.