Last night, I managed to read Lori Gottlieb's eye-catching piece from the Novemeber 23 edition of New York Times Magazine, "What Brand Is Your Therapist?"
I enjoyed the read, not least because, probably like a lot of people here, the thought of becoming a therapist is a favorite personal daydream. In her article, Gottlieb parts the curtain and gives a glimpse of what the practice of therapy is like from the other side: the search for clients, the struggle to establish empathy, the paradox of doing something for a living that thinks of itself more as a calling than as a lucrative profession.
Gottlieb goes on to claim that psychotherapy is in a crisis. After a hundred years, the supply of patients is drying up. Modern Americans, Gottlieb says, are in a hurry. They've are more results-oriented, especially as traditional psychotherapy comes under competiion from a new breed of 'life coaches.' They're less likely to be interested in the ho-hum hard work of the traditional therapist-patient relationship.
Her focus is on the growing pressure on psychotherapists to respond by 'branding' themselves: one consultant who helps therapists distinguish themselves from the pack encourages Gottlieb—once a full-time journalist, now a therapist growing her new private practice—to carve out a specific niche for herself. She mentions therapists who "became successful with specialties as narrow as treating tweens, alternative families, military wives, video-addicted teenage boys…and repeat D.U.I. offenders."
Other bits of offputting advice include harnessing the power of social media. Therapists, Gottlieb is informed, should be blogging and tweeting. The idea is to show potential clients that they are relatable, but the idea is anathema to psychotherapists trained in traditional methods, which hold that every piece of personal information a therapist divluges can hinder the transference that is necessary for a patient to make progress.
It's all very amusing—sort of laugh-and-groan-inducingly familiar to hear about therapy contorting itself to fit with the zeitgeist. Gottlieb recounts one prospective patient who ended up forsaking therapy with her to work with a life coach who promises to solve his issue (whether or not to marry his girlfriend) in four sessions or less.
"'Nobody wants to buy therapy anymore,'" one image consultant tells Gottlieb. "'They want to buy a solution to a problem.'" Public appetite for the slow, open-ended, sometimes painful work of discovery that traditional psychoherapy offers is at an all-time low. So therapy scrambles to present itself as something fast, chirpy, positive, and as focused as a laser beam.
But as entertaining as it is to blame our quick-fix culture for therapy's problems, there is another and bigger villain hiding in plain sight. Gottlieb mentions it herself in her lede. Noting that "psychotherapy is losing its customers"—to the tune of thirty percent fewer patients receiving therapy in 2008 than just 11 years before—Gottlieb lays out two facts. The first concerns the insurance industry. "Since the 1990s," she writes, "managed care has increasingly limited visits and reimbursements for talk therapy but not for drug treatment." Second, pharmaceutical companies spend over ten billion dollars a year promoting their products to physicians and consumers. That's almost twice what they spend on actually developing new products.
Psychotherapy doesn't have an image problem; it has a financial problem. While Americans are in a hurry, I'm willing to bet that the wish for immediate transformation, and the impatience with week-after-week deep work on the couch, has a lot less to do with Americans' real preferences, and a lot more to do with what Americans think they can afford.
In a 2009 study of trends in antidepressant medication use, Mark Olfson of Columbia University wrote, "[a]lthough depressed patients sometimes prefer psychotherapy over antidepressants, financial factors including out-of-pocket costs to patients and comparatively low third-party clinician reimbursement for psychotherapy have likely led to declining use of psychotherapy."*
When I was doing the research for Coming of Age on Zoloft, I interviewed one epidemiologist who specializes in psychiatric medication. She told me that the erosion of insurance company support for therapy is wrong and dangerous, for patients and providers both. "Why isn't the American Psychiatric Association marching on Washington and telling [Congress] that we can't do our jobs because the insurers will not pay for therapy?" she mused.
On a personal note, doing sustained psychotherapy for a couple of years in my twenties was one of the most valuable experiences of my life. Without generous insurance, provided through my graduate program, that allowed me to do that work for a reasonable out-of-pocket cost, I probably would have remained curious about 'real' therapy. My life would be different. And I might very well have been tempted by the services of a life coach who could have promised to contain my cost—with a fishy guarantee, the offer of twenty-minute sessions, or the promise of Twitter and text-message contact outside of office hours.
The push for psychotherapists to 'brand' themselves to appeal and compete in an ever more pressurized marketplace makes for a colorful story. But psychotherapy's "image problem" is ultimately a side-note. If the discipline is flailing, it's because insurance companies have stopped treating psychotherapy as a medical service, and have pushed it out into the marketplace where it must fight to survive. Meanwhile, the decks are stacked, because psychiatric drugs are protected as a medical intervention.
Anybody want to organize a march on Washington?
*Olfson, Mark, and Steven C. Marcus, "National Patterns in Antidepressant Medication Treatment," Arch Gen Psychiatry. 2009;66(8):848-856
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Katherine Sharpe is the author of the book Coming of Age on Zoloft: How Antidepressants Cheered Us Up, Let Us Down, and Changed Who We Are (Harper Perennial, 2012). Follow her on Twitter at @katherinesharpe, check out her website, or join her book's Facebook page.