Uhhh . . . what just happened to psychotherapy?
And what happens to psychotherapy practice from here? Do we continue to work across screens? Is Zoom fatigue our next source of therapist burnout? Should we keep our lease and see clients in the office, but maybe install plexiglass between us? Remember when our ethical questions dealt with whether or not to hug clients? Can you believe we’re now questioning sitting in the same room?
Psychotherapy as a profession isn’t known for rapid innovation, but due to current events, we’ve suddenly moved from a system that hasn’t changed much since the 1990s to the technocentric reality of teletherapy in a couple of months. We changed out of necessity, but what will a therapist’s practice look like going forward? Will it be the same as it was before COVID-19? Not likely!
Lynn Grodzki has spent much of her career helping therapists find their brand and niche while building a viable business model. As a psychotherapist, coach, popular speaker, and author of six books, including Building Your Ideal Private Practice, she’s thought about the future of therapy for most of her career. For the practicing clinician in the midst of career-altering transitions, her insight is needed now more than ever.
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Ryan Howes: I just signed a lease on a new office. Did I make a huge mistake?
Lynn Grodzki: It’s really hard to know, isn’t it? There’s talk that we could be in for another wave of this pandemic before the year is over. Hopefully, you’ll be able to use that office soon, but I think the timing is going to be different in different parts of the country. Here in Washington, DC, people are really cautious. It might be a while.
I feel that online therapy is going to have some legs: some people are going to stick with it, maybe forever. I’m hearing some therapists and clients like it a lot. It has real advantages, like cutting down on commutes and the ability to see clients from all over. Other therapists aren’t confident or comfortable with it. As a result, their clients are deciding that they want to take a break, hold off on therapy until they can be face to face.
I’m hearing a lot about retention problems, based on the shift in the framework of therapy. Part of the issue has to do with therapists’ comfort being in a role of persuasion. A great book, called Persuasion and Healing by Jerome Frank, talked about how a core tenet of psychotherapy is that you have to persuade people to change. Right now, mental health issues are on the rise, isolation is driving a lot of new anxiety and depression, and serious mental health issues are arising, so we have to persuade people that we can help.
We need to let people know that they may be vulnerable for more depression, and this may not be a good time to cut back on therapy. We have to be persuasive, as opposed to being passive. Some therapists feel they should let the client drive the therapy, which I totally understand and appreciate. But this is a crisis time, so I think we need to rethink our role here.
RH: I think a lot of therapists could hear “persuasion” and think “manipulation.” Aren’t a lot of therapists afraid of that?
Grodzki: Yes. It’s important to know it’s not about making people do something they don’t want to. Persuasion is about helping them understand the larger context and the expertise you can offer.
My colleague Joe Bavonese has a group practice in Michigan with over 20 therapists working out of several locations. In a recent interview, he said that some therapists were retaining clients as they moved to teletherapy, and others weren’t. At first, it didn’t make sense, because some of the people that weren’t retaining well were therapists that had never had that problem before. When they started to dig into the issue, they found that one of the variables might be therapists’ confidence in using new online teletherapy platforms, and relaying that confidence to their clients.
If the therapist says things like, “Hey, this is going to be good. I’m comfortable with it, and it’s not going to disrupt us,” it helps the client get comfortable, too. That’s a form of persuasion. If you’re trying to help a client approach some behavior in a new way, you might say, “You know, I really think you can take this next step, and I feel like you have the capacity.” That could be a form of persuasion also.
Think about the way the medical professionals have had to persuade us to wear masks and gloves and practice social distancing. They didn’t say, “Well, if you feel like it, it’s a good idea.” Because they were the experts, they said, “This could help you stay safe.”
If we know that people are particularly vulnerable right now, then I think it’s often appropriate as a professional to say to someone, “I don’t feel comfortable with you cutting back on therapy right now.”
RH: I’ve been talking with colleagues about how video sessions can feel so exhausting, and we’re not quite so sure what that’s about.
Grodzki: It really is different to be looking at yourself on screen in a session, or even looking at someone else with that kind of degree of exposure. The screen doesn’t hide a lot, and you’re so front and center. How exhausting is it in any job to be forced to look at a computer for so many hours every day? It’s really not ideal.
RH: And yet, a lot of therapists will probably say, “It’s worth forfeiting the commute and the rent of the office. I’m just going to stay at home and do this.”
Grodzki: I think this is going to be the new normal—not for everybody, but it’s going to be one of the platforms we’ll continue to use. So the challenge for us as therapists is how do you get more comfortable with it? Where’s your chair positioned? How are you set up? How do you make your clients more comfortable? How do you tweak your tried-and-true methods to make them work better onscreen?
I was talking with somebody who runs group therapy sessions, and I was fascinated to hear how that’s working on Zoom. She said, “We’re having to change a few things, and it’s becoming more of a conversation, less somatic and less dynamic.” But it’s still working because they’re processing together.
For many people doing couples therapy, their methods are reliant on the therapist’s being there and picking up subtle cues between people. They’re telling me that some things aren’t translating well to online therapy, but, of course, they’re adapting.
We’re all having to tweak certain methods to work in a new format. This is how things evolve. In fact, animals, plants, and humans evolve fastest in a survival situation. So I think our survival as therapists will depend on how open we are to seeing this as an opportunity, or how resistant we are to change.
Going back to in-person sessions will be a collaborative decision with clients, I think. Some might say, “I kind of liked when we met over video; that worked for me.” Or, “It was interesting to be in my room, and feeling so comfortable and talking to you. I felt safer.” Whatever good came out of it, we can keep that in place.
RH: Some of my clients are choosing phone over video. I think that’s really interesting. Those phone sessions are different. It’s almost like they’re on the couch and free-associating like old-school psychoanalysis.
Grodzki: It’s interesting to think about these things in terms of their clinical impact. But we should also be considering the business impact. As psychotherapists, we’re a small-business industry, and I was just reading in Forbes about how many small businesses won’t be able to make it through this. Unfortunately, not every single private practice, clinic, or outpatient center will be able to reopen, because many of these small businesses operate on razor-thin margins. They don’t have a lot of cushion and savings.
Some private practitioners who were thinking about retiring are going to feel like this is just too hard and close down. For those who do open back up, it may feel like restarting. I’ve been hearing some pretty big numbers about the falling off of clients who don’t come back after taking a break.
So now is a time when we need to do a lot more marketing or invest in different systems that address weakness in our business systems. Small business is always vulnerable. During the 2008–2009 recession, I saw many private practices shut down. This is much worse.
RH: It’s ironic that we’re hearing how great the need for our services are right now, and at the same time, our small businesses are shutting down.
Grodzki: A lot depends on how you run your practice. I hear insurance-based therapists are overwhelmed with clients, more than they can handle. But fee-for-service therapists are complaining about a client falloff. Some in Canada are experiencing a 60 to 80 percent client falloff.
I’ve always tried to be a translator for therapists about business. A lot of therapists don’t feel like they have a business, or that they’re businesspeople in any way. For that reason, most therapists don’t have any plan in place for an economic downturn. They’ve never thought about it, or they don’t have a lot of money put away in case of a drastic situation.
My hope is that this becomes more de rigeur in the future, and more therapists understand the risks, that this might happen again. If you’re going to be in small business, you have to do more of the things that a businessperson does, like consider all the economic what-ifs. The worst time to figure out a plan is in the midst of a crisis, when you’re anxious and panicked. It’s much better if you’ve planned ahead, and that’s what successful business people do: they’re always planning for the worst when times are good.
So if you’re not seeing as many clients right now, it’s a good time to build connections in the field and do things that might help your practice in the future. In the data, which aren’t always easy to gather because we’re so disparate in our practices, it appears that 50 percent of new clients find their therapist online, and 50 percent come from a referral.
You can’t just sit back and hope that your Psychology Today profile will do all the work for you. You’re going to need to refresh those real contacts that you have; that’s where the referrals come from. Just call someone up and say, “How are you doing? Thinking about you. Wondered how things are going.” Then let them know if you have some openings. Everybody’s in the same boat right now.
RH: Is there a way to recession-proof our practices?
Grodzki: When times are good and your practice is full, one of the things that often falls away first is ongoing marketing. Most therapists don’t enjoy marketing anyway; it’s not fun or interesting to them. But as a small business, they need to keep marketing, even if they think they have enough clients at the time.
Another thing they can do is create a newsletter or a podcast. Going regularly to networking meetings and a peer-supervision group are also things you should make time for, regardless of whether you’re full or not, that would bring in new clients.
If you’re marketing regularly, you’ll have an overflow, and you might have referrals to make to others. It’s better to say to a potential client, “I’m full, but let me give you some referrals,” than to have nothing coming in.
RH: What can you say to therapists right now to help them feel a little more positive?
Grodzki: In every crisis, opportunities emerge. Right now, some therapists are focusing on helping underserved populations. Others are developing a clinical focus on loneliness and talking about their work in that respect. Some are finding that a time like this requires them to focus on themselves to make sure that their own ways of dealing with anxiety or self-care get better. That’s going to benefit their clients in the end; it’s something they can pass on.
This is also a time when many therapists are getting a chance to learn new skills. Some are like, “You know, I’m going to learn QuickBooks, and I’m going to manage my billing myself.” Or, “I’m going to write an ebook.” Or maybe, “I’ve been thinking I want to work with eating disorders more. It might be time to rethink the direction of my practice.”
We’re discovering more about ourselves through this, and how to be better leaders in our own lives. Personally, I decided to take on some leadership in a local therapist organization. It felt like a good time to give back in that way. Similarly, we’ve got a really active listserv in my area, and it’s wonderful to see the way people are stepping up to be there for their colleagues: not just for their clients, but for each other. Therapists are coming together. Rather than feeling competitive, it seems they’re feeling more connected.
Ryan Howes, PhD, ABPP, is a psychologist, writer, musician, and clinical professor at Fuller Graduate School of Psychology in Pasadena, California. Contact: email@example.com.