Forks in the Road

by Lynn Grodzki, LCSW, MCC  (Private Practice Newsletter, Sept. 2010)

____________________________________________________________
Do you wonder where the profession of psychotherapy is headed, and specifically, what you will be facing in your own private practice in the future?

Given this uncertain economy, our profession is changing quickly. We are entering a new phase of psychotherapy; those who own and operate a private practice have some important choices to make. The way you position your practice today will determine where you end up in several years.

Think about the current situation as being on a road with several divergent paths. What path will you take or have you already taken?

Yogi Berra said, “If you come to a fork in the road, take it.” Unfortunately, too many therapists have followed this illogical advice and chosen a direction unconsciously, without understanding what it means.

This month’s newsletter is my recommendation about how you can become more deliberate regarding the direction and future of your clinical and business situation.

Please read on and, as always, I welcome your response.

The Future is Now

The business and practice of psychotherapy is changing. During uncertain economic times, the business owner who looks ahead usually survives and thrives.

Some therapists take the Yogi Berra approach. They build a practice based on circumstance, taking what comes instead of making conscious choices. In the demands of the daily issues of their practice, they lose sight of the big picture of their clinical direction and business vision.

For example, in one of my workshops, I asked the therapists to take out a blank sheet of paper and draw the direction their practice had taken from its start.

One therapist showed her drawing – a meandering line that wandered around the page. She explained, “I started out in an agency, then opened my own practice and saw anyone who would come in. Then every few years I got interested in a different method of therapy. Now I am seeing a lot of people with a lot of issues, somehow combining all of this. But I don’t really liking the work I do, or the hours I work, or the money I make. How did I get here?”

She chose a fork in the road, and it took her to a place of dissatisfaction. But she chose it unconsciously and felt surprised and dismayed by the result.

This can happen to any of us. But is this what you want?

Time to Wake Up

I try to be a trend-spotter. I spend a lot of time trying to see where we are going as a profession. I believe that, given the recession and other changes in the health care front, the future of psychotherapy and private practice is getting clear.

Therapists are going to choose one of 3 very different paths to walk. No matter whether you are in a solo private practice or a group practice, chances are you are already headed down one of these.

Is your path a conscious choice for you? I hope so, because each path has its pros and cons and risks and rewards. Each path will undoubtedly determine your clinical and your business approach.

Getting curious? I will give you an overview of each path, and then in future emails I will go deeper to explore these three, very different approaches to psychotherapy and the way to offer services, so you can make a conscious choice about your future.

The Three Paths

If you had been tracking the big picture of our profession during the past decade, you would likely agree that we have come to these three forks in the road.

Each path, in its philosophy, services offered, and business model, makes a strong statement  about who you are as a therapist and where you will end up in the future.

I will list the three forks in the road and then give an overview about each positioning. Each can best be described according to their primary motivator (what drives or determines the path.)

They three paths that psychotherapy and private practice follow today are:

1) Insurance driven
2) Consumer driven
3) Belief driven

I don’t believe any one path is intrinsically better than any other.

Your choice is a preference based on your clinical style, approach, values, and business goals. Each has its own structure and reasoning behind it, as well as its proponents and naysayers.

Read on to stay conscious and make the right choice.

The Insurance-driven Path of Psychotherapy

Many therapists walk this path without understanding why, only knowing that their clients want to use insurance, so they must sign onto managed care plans. But this path is a very conscious choice, with many pros and cons.

The insurance-driven path began in the 1950’s with the industrialization of behavioral health care. Psychologist and author Nick Cummings, then head of Kaiser, was one of the first to tie psychotherapy to insurance reimbursement. As this trend continued, insurance companies began to drive not only the payment but also the clinical direction of psychotherapy.

Evidence-based, brief treatments that could yield data, be easily assessed by reviewers, and cheaply delivered was a key to the success of this path. As a result, more and more psychotherapists got trained to work in the industrialized method.

Cummings says, “I see that psychotherapy’s either going to have to become part of the health system or lose out entirely…the golden age is over. The competition is fierce. We now have 700,000 licensed psychotherapists in the United States. We only have 750,000 physicians! So we have almost as many psychotherapists as we have physicians, and they’re all competing for a declining number of patients.” (“An Interview with Nick Cummings, PhD. by Victor Yalom”2008, see: http://www.psychotherapy.net/interview/nick-cummings)

If this is your path, you need to position your practice for the competition. Your success is determined by the industry (insurance) evaluation of your practice results. You need to achieve insurance-determined objectives to stay profitable and understand the recent concerns about current trend of insurance-driven therapy from efficiency to effectiveness.

I can help! In a future email newsletter, I will review Cummings’ newest work that outlines the mistakes therapists in insurance-driven practices often make, to help you understand how to best position yourself and your practice.

The Consumer-driven Path of Psychotherapy

Some therapists don’t want to tie their practices to insurance and an industrialized approach; instead, they have adopted a consumer-friendly stance and reached out directly to the consumer, to avoid the middle-man.

Consumer-driven psychotherapy focuses on meeting the needs of the client and getting their immediate feedback.

Measures and evaluations that incorporate client feedback have evolved in a specific way: the needs and wants of clients (consumers) have begun to shape the work of the therapist and the approach of the therapy.

The research and writing of Scott Miller (http://www.scottdmiller.com) best describes this client-directed, outcome driven approach. Using single session rating scales, Miller encourages therapists to stay in a feedback loop with clients. Improving therapist performance and outcomes relies on knowing how satisfied your client is with his or her sessions.

If this is your path, success is based on how the client reviews each session and the overall treatment. To survive and thrive in practice, you need to understand the structure, measures, and marketing that help a consumer-driven practice to succeed.

I can help! In a future email newsletter, I will showcase how one therapist is using the Miller measures to create a waiting-list, self-pay practice and improve his outcomes each month.

The Belief-driven Path of Psychotherapy

Belief-driven therapy is the most traditional path. It often resembles a Middle-Eastern bazaar. A plethora of professionals (psychologists, social workers, marriage and family therapists, counselors, and psychiatrists) promote and use a myriad of approaches (over 180 schools or methods of therapy) including conversation, written word, artwork, drama, narrative story, bodywork, and music.

Without substantiating evidence for one method over another, therapists in the traditional system operate based on their belief about what methods and approaches are best. But this belief-driven focus is not without logic.

One piece of research supports this diverse approach, a study known in the profession as the Dodo Bird Effect. Psychologist Saul Rosenzweig (1936) found that therapeutic orientation doesn’t matter because all orientations work.

As author and therapist Gary Greenberg explains, “The Dodo Bird Effect has been borne out by numerous studies since, with one elaboration. The single factor that makes a difference in outcome is faith; the patient must believe in the therapist and the therapist must believe in his orientation. For therapy to work, both parties must have faith, sometimes against all reason, that their expedition will succeed.” (“The War on Unhappiness,” by Gary Greenberg, Harper’s Magazine, 9/2010.)

Therapists who operate a belief-driven practice usually rely on fee-for-service payments and this will increase in the future since non-industrialized, evidence-based methods will probably be cut out of health care reform. If clients want what Greenberg calls the “essential healing relationship” they will pay for it out of pocket, similar to alternative medicine.

If this is your path, success will rely on your reputation, passion, expertise in your approach and be measured by you, the therapist. Your practice will rely on how you create healing relationships with your clients. You need to become savvy as a communicator, entrepreneur and  know the best practices and best business model for a fee-for-service practice.

I can help! As always, I will help any and all “reluctant entrepreneurs” understand the business of therapy, which I have and will write more about in future newsletters.

Summing Up

As you can, each of these paths is here now and your choice of which to follow determines how to measure success, what to focus on for the future, and how to communicate your approach to the those who will assess and evaluate your services.

(Copyright 2010 by Lynn Grodzki, all rights reserved. Reprint by permission of author only. To reprint, contact: lynn@privatepracticesuccess.com. Spread the word, a high tide lifts all boats.)