For the last 20 years I have been watching what has been happening to psychotherapy, starting with the blessing that wasn't, third party payments, continuing to the present with the dominance of managed care and drug companies in setting policy. And what is happening runs quite counter to what is popularly believed about the field and its practitioners.
Psychotherapy Networker this month contains a number of articles about this very issue. And Lynn Grodzki spells out what too few outside the field understand:
"...last year, Psychotherapy Finances, a newsletter for behavioral health providers, released an industrywide survey of those in private practice and confirmed my observations. After 20 years of relative income stability, the financial picture for psychotherapists it described was dismal. With managed care on the rise, senior professionals surveyed, such as social workers, reported an inflation-adjusted 22-percent decline in overall income since 2000. Those who depended on indemnity insurance or self-pay clients reported problems keeping their caseloads full. A combination of factors led to the decline, but I'm convinced private practice stands at a crossroads of viability today...
According to the survey, the average licensed counselor, social worker, or marriage and family therapist in full-time private practice is earning a "salary" or net profit—income minus hefty practice expenses—of only $30,000 a year. The main reason for the drop in income is that managed-care fees for individual sessions, which account for 43 percent of the average practitioner's income, haven't risen for a decade, languishing at around $75 at the high end and $60 at the low end for a 50-minute session.
It's not that there isn't enough money: according to Plunkett Research, a company that specializes in health care market analysis, health spending in the U.S. is at about 16 percent of the gross domestic product, and growing. But the money funnels primarily through managed care delivery systems, which are disinclined to promote mental health. John Klein, editor of Psychotherapy Finances, notes that 15 years ago, the health care consultants he talked to found that 10 percent of all insurance dollars went to pay for mental health services. "Today, the figure I hear from the consultants is closer to 1.5 percent," he says, sounding discouraged."
The problem too seldom acknowledged is two-fold: first, insurance companies seduced the everyone by promising coverage which in turn created for many if not most therapists a serious dependency upon them as the only way to get paid at all. It has been an abusive relationship from the start, with the controlling partner, the insurance companies, creating ever changing rules and hoops to jump through, lowering payments and punishing any who dared to complain. So, too many therapists cower and watch their practices disappearing because they believe they cannot survive without being on managed care panels and playing the submissive game with them.
The second problem is that there are at least 5 categories of professionals who practice as psychotherapists but instead of speaking in a single voice, as psychotherapists, each group fights to guard its own little piece of the turf as the territory as whole gets whittled away bit by bit. The way the system is structured, with different payment schedules for each discipline, fragmentation is reinforced because joining together might result in everyone getting less.
The only solution I can see is for us to get out of the whole game. Which means dropping the medical model and turning to looking at psychotherapy as a kind of personal education rather than a medical treatment. The ICD-9 and CPT codes for individual psychotherapy* is called "medical psychotherapy", which I suppose is different from non-medical psychotherapy. But to tell the truth, having read very widely in the psychotherapy literature and having participated in workshops and seminars on all kinds of psychotherapy issues and techniques, I have never seen this term used outside of the ICD-9 and certain psychiatric circles -- because it claims psychotherapy turf for psychiatrists, not because they have special therapy skills but only because their training is in medicine rather than psychology or social work.
There is no point in debating about "brain illness" or any of the rest of it because what we do no longer fits, if indeed it ever did, under the medical model. There is no point in arguing with insurers about the legitimacy of therapy other than CBT done short term. That train left the station a long time ago.
Instead of focusing on how we can help with symptoms, we need to make it known, through what we write, talks we give, courses we teach, how therapy can broaden life, making available a wider array of choices and greater freedom in making them. How it helps people develop tools for dealing better with friendships, marriage, children, colleagues. It isn't about curing or healing. It's about making lives better, richer, more meaningful. We need to look at a wider variety of ways to offer our services, including online. But most of all, we have to extricate ourselves from the abusive relationship with managed care and be willing to leave behind our role as the bastard children of medicine.
* these codes are used on health insurance claim forms to describe the services rendered.