Maintaining a Psychoanalytic Practice in a Tough Economy

We psychoanalysts face unprecedented challenges these days in maintaining a fulltime private practice. The more we can discuss these challenges and questions openly and thoughtfully, the more likely we will be able to successfully create or develop potential solutions. Doing so, however, is often problematic, since we do not like acknowledging in public forums, or even to individual colleagues, that we are having trouble keeping our clinical hours filled. I am not only addressing whether or not we have enough analytic patients, as it is well known now that most analysts across the country or around the world, do not spend the majority of their clinical hours doing four or five times per week analysis. Clearly, there are some analysts who have a full schedule of analytic patients but they appear to be a minority.

Here is a snapshot from my practice. Carla, a 35-year-old married woman with one young child, was referred to me by a colleague three months ago. She is completing a mental health degree and felt it important to have her own treatment. Her husband had to take a job in another state, since he did not think his company in Michigan would survive much longer. Carla actually wants psychoanalysis but her insurance only allows for 25 sessions per year. Since she and her husband support two residences and she is still in graduate school, she cannot afford any more than her co-pay of $35. Per week. Thus, we meet on a weekly basis using her insurance.

Mike, another recent referral, is a 30-year-old single man who recently lost a girlfriend due to his angry outbursts. He was emotionally and physically abused for years by his father. His prior attempt at treatment ended unsuccessfully. In order to see me, he cannot use his insurance as I am out of network and he was told he could get no reimbursement if he sees me. We worked out a fee he could afford, more than a third less than my standard fee. Despite these accommodations, he eventually chose to see someone else so that he could use his insurance.

I am aware that both of these patients would be advised to have more intensive treatment, preferably analysis, but neither will for now, if ever. If I can, I will reduce my fee further to enable one or both to come in more frequently. These are no longer unusual situations in my practice. I am glad to have these referrals, am still receiving a decent fee, even though it is increasingly rare to have someone able to pay my standard fee.

The current economic turmoil, now officially a recession, is another wave of powerful external forces that is profoundly affecting practices across the spectrum of experience. For many years, I felt strongly insulated from these forces. In addition to seeing individuals in psychotherapy and psychoanalysis, I also treat couples. My practice had rolled successfully along for years but the severe economic struggles have finally caught up with me and many of my colleagues.

The question we face now is whether or not the recession will become a tidal wave, wiping out psychotherapy and psychoanalytic practices as it has many other businesses. We appear to be experiencing a third wave of external forces that profoundly affect practice.

The Smorgasbord and the HMOS

The first wave, which occurred when I entered the mental health field in the late 1960s and early 1970s, was the rapid development of alternative modes of therapy. Drug treatment is now sought and frequently recommended for nearly any problem. Cognitive-behavioral, brief psychotherapy, group therapy, hypnotherapy, trauma treatments, dialectical behavior therapy, and others are all part of the mental health therapy cafeteria. Who knows which of these many alternatives will survive over time but, as many have noted, we are no longer the only game in town and not necessarily the dominant one.

The second wave was the insurance industry's move from indemnity insurance to so-called managed care, in which mental health benefits were severely cut or restricted. Long-term psychotherapy, let alone psychoanalysis, was brought under much closer scrutiny. The number of sessions per year, the dollar amount covered, and the frequency of treatment sessions are all regulated by insurance companies. Of course, there will always be those patients who can and are willing to pay out of pocket and that was how many of us built successful practices. Even that, however, has changed under these severe economic pressures.

Therefore, the question before us is: What are the ways to cope with and adapt to these challenges individually, as well as at a local society and national level? Individually, we can think about whether or not we are using the full range of our training and skills to our best advantage. For me, this has meant doing psychodynamic couples therapy, something I worked into my practice during an earlier recession. At many times, these couples referrals kept me going. In my area, there are simply not that many analyst colleagues who do couples work. Clearly, most of us try to create some niche by which we are known among our primary referral network, our analytic colleagues. The stretching of ourselves out of familiar comfort zones may be inevitable, if we are to maintain enough work. Joining insurance panels, reducing fees, seeking new sources for referrals may already be underway for most of us.

Once a solid practice is established, many analysts have tended to stay within the two main sources for referrals: patients or former patients and analytic colleagues. The use of Web sites, blogs, and other Internet based connections has helped many but may not work for others. My point is that a passive stance regarding these problems will lead nowhere. Sitting back and waiting for the phone to ring may have worked in times past but that does not appear to be the case now.

We also may be called upon to think about what we do in terms of its effectiveness. More new patients in recent years have asked me straight away: Have I treated these problems before and what is my rate of success in doing so. While there are obviously underlying dynamic meanings to such questions that eventually got addressed, I do not think we can brush them aside as only initial resistances.

Coping, Adapting, and Countertransference

There are some countertransference vulnerabilities to bear in mind. For example, when faced with declining subscriptions in our practice, we may have more difficulty dealing with a proposed termination or the move to cut back on treatment hours. Several colleagues have mentioned to me with much concern about the pending termination of an analytic patient, losing four or five hours per week at once and also stating there is no one in the wings to replace those hours. Clinical exigencies of patient work may collide with our own pressures to make a living. Moreover, we might find ourselves taking on certain kinds of work for which we may not be prepared, thinking that we can learn as we go. One colleague told me how he took on some “expert” testimony work in order to supplement his income and soon realized he had little actual preparation to do so. We might accept a referral of a friend or relative of a patient that under other circumstances we would pass along but may find a way to justify taking the referral. I am sure there are many more instances we can enumerate.

Finally, while psychoanalysis may have lost its once preeminent place in the mental health world, those of us who have done the training know that we have been incredibly well trained in the most in-depth treatment of the psyche ever developed. This superb training has served me well, no matter what form of treatment I am doing and will continue to do so. We all may have to adapt to changes we have not yet assimilated, but if prior experience has some predictive value, we will be able to make a successful adaptation.

Editor's Note: The patient information in the clinical vignettes has been disguised to preserve confidentiality.