Times are hard, and in the news we’re told that the economy will get much worse before it gets better. In times like these therapists in private practice need to think about changing the focus of their work so as to protect revenue streams.
Note to patients: Please do not read the rest of this post. It contains ideas that you might find puzzling or worrying, and which might tend to de-stabilise your life-long relationship with your therapist.
Therapists in private practice have to remember that they are running a business, and have to see their work to some extent in terms of business strategy. Of course the business’s product line is therapy, and that’s the focus of day-to-day operations. Business strategy, as such, usually stays in the background.
The business model underlying the practice of therapy is usually established when the business is set up, and there’s a temptaion just to leave it alone thereafter. But all businesses operate within the general economy, and an economic downturn like the one we are suffering now can necessitate a change of strategy.
Businesses that fail to adapt are at risk of failing to survive.
Therapists in employment would be wise to give consideration to the same economic issues. Even in the NHS, which is currently pouring money into certain kinds of therapy, individual therapists are vulnerable.
The money that is being spent by the NHS today is from a government that based its finances on borrowing. Interest payments on that borrowed money, and eventually the need to pay it all back, will lead to inevitable cutbacks.
In the short term, therapists whose training is not in CBT will find it increasingly difficult to justify their continued employment. They can take steps right now to pre-empt unfavourable comparisons with CBT therapists.
In the medium term, even CBT therapists will be at risk from cutbacks when government spending falls back to affordable levels. And in the long term, CBT is certain to be replaced by some other brand of therapy (although I see no sign today of what that might be).
So therapists in employment should have similar concerns to therapists in business, and those concerns should lead them to consider similar strategic shifts in the way they do their work.
In good times, success in business as a therapist is all about success in your core product line: curing patients. If you are not successful in that, you will go out of business.
So there’s a steady stream of incompetent therapists who train, set up in business, survive for a while, and then go bust. The time it takes to go bust is surprisingly long, because it depends on the therapist’s reputation collapsing as word gets around that the therapist cannot deliver, and that’s a slow process.
I estimate that the time to go bust is very roughly eight treatment cycles. So for an incompetent CBT therapist, who completes treatment in an average of a few months, it’s possible to survive in business for a couple of years.
The corollary, of course, is that CBT therapists who have been in business for much longer than a couple of years must actually be curing people, but most patients don’t know that.
An alternative strategy for staying in business is to lengthen your treatment cycle. For example, if you are an incompetent psychodynamic therapist with an average treatment cycle of five years, then it might take about forty years for you to go bust — and forty years is a fine career.
But in good economic times few patients will put up with long treatment cycles. There’s competitive pressure on your business from colleagues who can treat people faster and more successfully. In good times the optimum strategy is high turnover and high success rates — treating your patients quickly and effectively.
In bad times the logic changes. Employers cut back on private health insurance. People are less willing to spend their own money. People who are still have jobs are less willing to take time off work to go for treatment. All these factors mean that there are fewer patients to go round.
Treat patients too quickly in an economic downturn, and you will be left with not many patients to treat. That’s why a more appropriate strategy is to slow treatment down. Lengthen the treatment cycle and reduce your turnover to stay in business.
An appropriate goal is to lengthen your treatment cycle by between two and three times. For example, if you are a CBT therapist able to treat moderate depression in around six sessions, then you should be aiming to stretch this to between twelve and eighteen sessions. If your normal Gestalt treatment cycle is 16 sessions, then you should be aiming for 30 to 50 sessions.
The ways you can do this are well known, because they are practised regularly by incompetent therapists. But what incompetent therapists fail to realise is that you have to be competent to make the techniques work.
You have to keep your patients coming back without actually curing them. If they think you are useless, they will leave. If they get better, they will leave. So you have to get the balance just right, and the way to do that is by creating dependency.
Techniques for creating dependency are all based on control. If you cannot control your patient, then you are in a no-win situation — either your patient will leave because you have not improved matters, or your patient will leave because you have improved matters. Dependency is an intermediate state in which the patient stays in therapy without improving. You can only achieve this through control.
Without going into all the details, I’ll outline a few basic tricks that you will probably need to master to create good patient dependency.
Set the agenda
A basic technique to learn is setting the agenda in every session. This is fairly easy because in a patient’s very first session he is not sure what will happen. So the patient always lets you set the agenda in the first session.
All you have to do is make that the pattern and keep it that way. Patients sometimes have a keen sense of what causes and maintains their problems, and they will make that their agenda if you let them. You must plan ahead to avoid letting the patient’s agenda take over, in case the patient improves too much and leaves you.
Keeping control is partly a matter of seeming distant when the patient is talking about the things that matter most to him. When the patient gets no response from you, he is unlikely to have the confidence to follow up. Always balance this, however, by seeming very concerned and sympathetic about things that do not really matter much, because they are safe topics to return to again and again.
Be mis-directive, not non-directive
A non-directive style often helps patients to move forward in their thinking, and this is something that you must avoid. On the other hand, if you are simply directive, then it gives the game away. As in much of this work, there is a balancing act. You have to appear to be non-directive while at the same time maintaining control.
For example, a directive way to start a therapy session is: “Aren’t you any better yet?” There is a risk that your patient will say “No” and leave.
A non-directive way is: “How are you feeling?” There is a risk that your patient will start exploring her emotions and improve.
A mis-directive way is: “How was your week?” This appears to be an innocent open question, but it subtly guides your patient away from what’s really bothering her in the here and now. So with any luck you get to chat about day-to-day trivia, and leave the difficult stuff for another time.
Patients like to be diagnosed, to know what’s wrong with them. So if you meet a patient for the first time and it’s obvious within ten minutes that he was emotionally abused by his drunken father, it’s important not to blurt that out.
Instead, go through a full diagnostic process, preferably involving some lengthy questionnaires. When you move on, don’t move on to treatment. Move on to more detailed diagnosis. Try to avoid a diagnostic focus on areas that are obviously problematic. For example, in the case above, a focus on relationships at work or on sleep patterns would be good choices for prolonging diagnosis.
In CBT, the infamous daily thought record sheets are a useful tool. A skilled practitioner can keep patients filling these things in month after month, simply by avoiding coming to any firm conclusions about the results. Patients like them because they can look forward to discussing them in the next session, and that reinforces the useful idea that there will always be a next session.
Towards the end of a session, try to create a feeling of suspense about the next session, so your patient has hopes and expectations of it — something to look forward to. That feeling that the next session is always something to look forward to is an important part of the dependency you are trying to create.
The cliffhanger is a moment of high drama right at the end of the session, so that there is no time left to resolve it. To create a cliffhanger, shift the conversation towards a subject that you know will get an emotional response from your patient, but do it in the last ten minutes of the session.
The technique requires skill, because you want to leave enough time for your patient to experience deep emotion, but not enough time for any real change to come of it. Obviously, you must keep a record of the cliffhanger in your notes because in the next session you must be very careful to avoid returning to the subject until, again, near the very end.
Cliffhangers have the added advantage of associating therapy with strong emotion. Many patients will come to think that you can control their emotions (which, in a sense, you can) and that this means you are a wonderful therapist.
Flog dead horses
There is a famous prayer, known as the serenity prayer:
God grant me the serenity to accept the things I cannot change, the courage to change the things I can, and the wisdom to know the difference.
Your task as a therapist is to create a feeling of serenity for your patient around those things in life that could be changed, because a patient who makes changes is a patient who will soon stop attending.
At the same time, help your patient to bring the full force of their emotional honesty and courage to bear on things they can do absolutely nothing about. Past relationships, especially with long-dead parents, are the staple of this technique.
Work the boundaries
Finally, be aware of the boundaries of the therapeutic relationship, and go right up to them.
For example, every therapist knows that it is imperative to avoid inappropriate touching. But there is also appropriate touching, when your patient is upset and in need of human contact. By being the human who provides the contact, you can make a relationship that is more than just therapy, and harder for your patient to break out of.
And don’t miss out on opportunities for your patient to do things for you. For example, if you have to rearrange an appointment, make it clear that you regard it as a personal favour.
Or perhaps you learn that your patient knits bobble hats. Ask for one, or buy one if that’s what it takes. Again, this kind of thing establishes a connection that goes beyond therapy.
Going beyond therapy — beyond mere expectations of change and cure — is the key to truly lasting revenue streams in therapeutic work, and the key to surviving economic recession.