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What Brand Is Your Therapist?
Illustration by Matt Dorfman. Photograph by Jens Mortensen for The New York Times.
By LORI GOTTLIEB
Published: November 23, 2012
In the summer of 2011, after I completed six years of graduate school and internship training and was about to start my psychotherapy practice, I sat down with my clinical supervisor in the Los Angeles office we’d be sharing. It had been a rigorous six years, transitioning from my role as a full-time journalist always on tight deadlines to that of a therapist whose world was broken into slow, thoughtful hours listening and trying to help people come to a deeper understanding of their lives. My supervisor went over the filing systems, billing procedures and ethical quandaries like whether to take referrals from current clients, but we never discussed how I would get these clients. I fully assumed, in what now seems like an astounding fit of naïveté, that I’d send out an e-mail announcement and network with doctors, and to paraphrase “Field of Dreams,” if I built it, they would come.
Except that they didn’t. What nobody taught me in grad school was that psychotherapy, a practice that had sustained itself for more than a century, is losing its customers. If this came as a shock to me, the American Psychological Association tried to send out warnings in a 2010 paper titled, “Where Has all the Psychotherapy Gone?” According to the author, 30 percent fewer patients received psychological interventions in 2008 than they did 11 years earlier; since the 1990s, managed care has increasingly limited visits and reimbursements for talk therapy but not for drug treatment; and in 2005 alone, pharmaceutical companies spent $4.2 billion on direct-to-consumer advertising and $7.2 billion on promotion to physicians, nearly twice what they spent on research and development.
According to the A.P.A., therapists had to start paying attention to what the marketplace demanded or we risked our livelihoods. It wasn’t long before I learned that an entirely new specialized industry had cropped up: branding consultants for therapists.
I couldn’t imagine hiring a branding consultant to lure people to the couch. Psychotherapy is perhaps one of the few commercial businesses that doesn’t see itself as one, that views financial gain as unseemly when connected to the delicate work of emotional insight. Moreover, the field is predicated on strict concepts of authenticity, privacy and therapist-patient boundaries. Branding was the antithesis of what we did.
But a couple of months after setting up my office and waiting for people to call, I found myself wondering — first idly, then deliberately, and always guiltily — about those branding consultants and how exactly they helped therapists like me. Sitting at my desk one morning when my appointment book looked particularly dismal, a combination of curiosity and desperation got the best of me. On Google, I came across a branding consultant named Casey Truffo. Her Web site’s home page spoke directly to my situation: “You are called to be a therapist. Are you also called to poverty?” I immediately dialed her number.
The first thing Truffo told me when I reached her in her Orange County office was that I shouldn’t feel bad about my empty hours; nowadays, she said, even established veterans were struggling. Yes, the economy was bad, but the real issue was that psychotherapy had an image problem.
She told me about a therapist named Sandra Bryson. In 2009, Bryson called for help after her successful Oakland-based practice of 25 years lost patients when she stopped taking insurance. According to Truffo, Bryson shared a problem common to therapists: “a blah-sounding message and no angle.” Bryson had always done well as a generalist — treating anything from depression to grief to marital issues — but Truffo urged her to find a specialty, one that “captured the zeitgeist but didn’t feel played out.” Bryson mentioned that she liked helping parents and had an affinity for technology, and voilà — suddenly she had a brand. Not as a clinician addressing typical parenting issues like boundary-setting, which Truffo called “generic and old-school,” but as an expert who helps modern families navigate digital media. She also became a sought-after speaker on so-called hot issues like screen time, cyberbullying and sexting, and Bryson told me her practice, which is based on “mostly deep work,” had become “more advice-driven.” Now her schedule is full, and her income has increased about 15 percent a year.
“Nobody wants to buy therapy anymore,” Truffo told me. “They want to buy a solution to a problem.” This is something Truffo discovered in her own former private practice of 18 years, during which she saw a shift from people who were unhappy and wanted to understand themselves better to people who would come in “because they wanted someone else or something else to change,” she said. “I’d see fewer and fewer people coming in and saying, ‘I want to change.’ ”
From a branding perspective, the fix was simple. At professional-networking events or in newsletters, her pitch went from “I treat people with depression and anxiety” to “Are you having trouble with the difficult people in your life?” Of course, therapy isn’t about changing someone else, but that wasn’t the point. If she could get people in treatment and help them feel better, she explained, why did it matter how she spun her pitch? Her goals seemed valid, but the idea of pitches and branding still made me uncomfortable.
It’s not that I didn’t understand the value of a sales pitch. In all my years as a writer, I was constantly having to package myself to sell books. But I was attracted to my new field because psychotherapy was about as far away from marketing as you could get. It was intense, personal work; it was as simultaneously simple and profound as sitting in a quiet room with another human being, technology turned off, helping them transform their lives in meaningful ways. Hocking my clinical wares like a Toyota dealer felt bizarre, so bizarre that while I resolved to start hustling and getting my name out there at networking events with other therapists, I certainly wasn’t going to create a so-called brand.
Three months into private practice, I had exactly four regular weekly clients. If I were a Toyota dealer, I’d be out of business. To make things seem less grim, I booked my clients back to back, so when the green light indicating that my next session had arrived went on, I felt as if I’d reached the place I labored so hard for. The work was immensely gratifying. My clients delved into their sessions. Couples found ways to connect. Others began to see how they were holding themselves back. But when the light stayed dim at the end of that last hour, I was faced with the gap between my notions of what I assumed for so long would be a thriving practice and the reality of a near-empty one.
One evening at a networking event (most were attended by equally underemployed clinicians), I was invited to a group in which therapists could talk about their struggles. A support group for failed therapists? I wasn’t sure whether to laugh or cry, but I took this as a sign that my ideals weren’t going to be enough to make this work. A colleague who told me she had some success turning around her practice by marketing herself with YouTube videos persuaded me to create a Web page so at least I’d be searchable to potential clients. She suggested that I call Alison Roth, who started the firm ShrinkWr@p (tag line: “Web sites even Freud would envy”). During my free consultation, I told Roth that I wanted a simple, professional-looking Web site, but she told me that wouldn’t be enough. She said the same thing as Truffo: If I wanted clients, then I needed a brand.
Picking a therapist is “not the same as choosing a good cardiologist, who you might see twice a year and will never know about your massive insecurity,” she explained. “Therapy is a very intimate experience. People need to like you when they Google you. They want to feel an immediate personal connection.”
I knew she was right. Many people admit that a sense of connection is more important in choosing a therapist than the clinician’s reputation or training. One woman told me that she chose her therapist because “she looked relaxed” in the photos on her Web site, “and I didn’t want anybody too intense, because I’m really high-strung.” A man explained that he found his therapist via referral, but “the Web site sealed the deal, because I discovered that her father was a Holocaust survivor, and I knew that was territory I needed to visit.” Another woman chose her therapist because her blog revealed that she had successfully overcome “food issues” in college, something this client was struggling with.
But disclosing this sort of personal information has always been tricky for therapists — in graduate school, psychology students are instructed not to display family photos in their offices and even to choose carefully the types of magazines they place in their waiting rooms — yet savvy branding specialists encourage just those kinds of subtle revelations. If you’re a parent, if you’re gay, if you’ve suffered from chronic illness, if you’re a child of divorce, if you’ve lost a loved one: sharing this, they say, makes clients with a similar history feel that you “get it.”
I mentioned this to my colleague Dina Zeckhausen, who has been practicing in Atlanta for more than 20 years, and she said she had seen this change, too. “It used to be that if somebody asked about your personal life, you’d reflect that back and interpret why they’re asking and what it means,” she said. “People don’t put up with that anymore. If you’re that way, they’ll say: ‘That therapist was so aloof. I felt so uncomfortable. It was such a weird interaction.’ But as therapists, we lose useful material we used to get in the transference.”
Essentially, “transference” is a jargony way to describe what happens when a patient redirects unconscious feelings toward the therapist, who is often serving as a stand-in for someone else in his life. A patient might idealize or devalue his therapist; he might conflate him with a parent or spouse or the boss who fired him five years ago. When the therapist remains somewhat of a blank slate, an unknown beyond the four corners of the office, these redirected feelings can then be effectively acknowledged and examined. But the concern is that the more details a patient knows about his therapist, the less likely he is to transfer unconscious feelings, the less chance the therapist will have to identify what really trips the patient up and the less opportunity the patient will have to truly understand himself and, ultimately, change.
Even so, most therapists I know are becoming aware that they need to project more than a tabula rasa. Roth suggested to me that in addition to creating a Web site, therapists should set up Facebook and Twitter accounts (she gives instructions on how to create social-media boundaries, like whether you’ll respond to clients’ posts), blogs, real-time appointment schedulers, teletherapy that’s compliant with federal privacy rules and other features that allow potential clients, she said, “to feel personally connected to you at all times.”
I felt my stomach lurch. I had just learned in graduate school why the formal structure of the 50-minute session works so well: It gives people a designated space and context in which to delve into difficult issues and then leave safely, without wounds exposed. I’d also seen firsthand, by making rookie mistakes during my internship, how breaking “the frame” can interfere with treatment. Constant communication can create a false sense of friendship and also undermine the development of coping skills: the ability to tell the difference between normal states of sadness or anxiety that pass and a true state of emergency. If clients need more, my supervisors always said, they should increase their weekly sessions, not be in touch in between.
I told Roth I had no desire to tweet daily aphorisms or to blog for my patients. “Let’s just focus on the Web site,” I said, “no bells and whistles.” She had two recommendations: addressing viewers in a video on the home page (“to move forward that first meeting in the office”) and coming up with “connecting questions” to bring in my to-be-determined target demographic. She gave me some examples: Is your daughter making choices you’re worried about? Would you like your partner to do more of some things and less of others? Are there people in your life you’d like to say no to? I’d also need a specific tag line, like “Make your home a happier place” (for parents with unruly teenagers) or “Find your way back to love” (for disgruntled couples).
“People want to see the therapist who fits their exact situation,” Susan Giurleo, a branding consultant outside Boston, told me. Giurleo said she gets 10 calls a week from struggling therapists. One of her clients, Kathy Morelli, filled her practice by becoming the go-to therapist for birth trauma and other pregnancy issues, an area Giurleo called “a thriving but untapped market.” Other therapists, she said, became successful with specialties as narrow as treating tweens, alternative families, military wives, video-addicted teenage boys, kids with Asperger’s syndrome and repeat D.U.I. offenders.
The one thing I enjoyed most was the wide array of cases I saw, I explained to Roth, and if I specialized, I’d be doing too much of the same thing all day. She suggested that if I wasn’t ready to commit to a niche, I could add life-coaching services to appeal to “today’s consumer looking for quick solutions rather than long-term insight.” When I balked — I couldn’t picture “Lori Gottlieb, life coach” — she assured me that many therapists who prefer deeper, broader work also offer coaching as an adjunct to their practices.
“If you think ‘coaching’ is cheesy,” she persisted, “you can call it ‘consulting.’ ” I thought about the word “consulting.” This way, she explained, I could get clients from all over the country, not just California, where I’m restricted to practice. I thought about my empty hours. Isn’t the room in which we do therapy called the consultation room?
That weekend, I sent an e-mail to my mailing list announcing my consulting services. Within days, astonishingly, I had seven consultations set up. A typical one went like this: A stranger would request an appointment, sign a release, set up a call and, at the agreed-upon time, the voice on the other end would present an issue — power struggles with kids, uncertainty about a career path, ambivalence about staying in a relationship, confusion over fertility options. I would listen and ask questions until I got the gist. Then I’d spend the remaining time helping this complete stranger identify the stumbling blocks to reaching his goal and point him in a more productive direction. Next!
I felt a little bit like Lucy with her psychiatrist stand in “Peanuts.” I’d purposely steer the discussion away from complex issues, like family dynamics, because they can’t be dealt with in a mere 50 minutes. Worse yet, broaching sensitive material in a one-time session could even be harmful. Instead, these consultations remained superficial, and they always ended on a high note, with clients telling me how helpful they were. But I wondered how long those feelings would last. Long-term change involves understanding the motivations, hidden conflicts and impulses that drive us. Whenever I had the urge to make an interpretation or ask a probing question, I had to keep reminding myself to let it go.
When I told my supervisor about these consultations, she had a bunch of questions, the primary one being: What, exactly, was the treatment provided? As I tried to explain it, she maintained a look of studied neutrality and nodded in the careful way I do when I’m trying to replace judgment with empathy for a patient who reveals that he slept with his wife’s best friend. Justifying life-coaching to a well-respected psychodynamic therapist felt a little like being a teenager trying to persuade my mom that Madonna was as musically significant as Mozart. Yes, I was helping people, but no, it wasn’t psychotherapy. (Even my contract said so.)
There was another issue: I was embarrassed to admit to my mentor that despite all the ways in which coaching fell short of therapy, there was something secretly satisfying about talking to a person for a single session and having her feel better. No tears, no frustration, no need for all those tissue boxes.
I’d recently seen a satirical YouTube video sent around by my colleagues, in which a psychologist urges her mentee to become a life coach instead of going to graduate school. I used to find it funny, but now I saw its truth. Coaching was indeed more profitable (the coaches I knew charged more than most therapists) and less arduous than therapy. The more coaching calls I got, the more I started to worry that I was falling prey to the same consumer-friendly forces — there are even iPhone apps for depression and anxiety — that were making coaching such a popular alternative to my own field.
One day right before Christmas, I got a call from a man in his early 30s about coming in for therapy. He explained that he wanted to figure out whether to marry his girlfriend, and he hoped we could “resolve this” quickly because Valentine’s Day was coming up and he knew he either had to produce a ring or she’d bail. I explained that I could help him with clarity but couldn’t guarantee his timeline. The day before our appointment, he called again and told me he found a relationship coach to help sort things out. She gave him a four-session-package guarantee.
There’s not a lot I can do when this happens, primarily because therapists, governed by a board, can’t make outcome claims the way coaches can. One popular parenting coach, for instance, posted this on her site: “You will feel empowered and at peace. Handling the day-to-day struggles will be a breeze. You will be able to rest assured, knowing that you have provided your kids with the foundation they so desperately need in order to be successful in all areas of their future.”
I compared this with the Web site of a therapist colleague, who answered a question about treatment expectations like this: “For most people who seek therapy, they find a feeling of catharsis in sharing their story of suffering with an objective, caring therapist. On the other hand, for some, it may have to get worse before it gets better. I think of it as opening a scar, which may bleed and be painful, such that the wound can reheal in a healthier manner.”
Blood and pain? Who wouldn’t choose the coach? I remembered something that Casey Truffo told me. A few years ago, she was at a business-networking event and wrote “psychotherapist” on her name tag; nobody wanted to talk to her. At the next event, she wrote the words “happiness locator” and got several referrals. In the past, going to a life coach might have seemed tantamount to a snake-oil cure, but now psychotherapists were branding themselves to play down what they do and what credentials they hold. I added up the money spent on grad school, the years it would take to pay off the loans, the time spent on training, the commitment to helping people that brings most of us into the field in the first place, and I knew I wasn’t willing to leave. My only choice now was how far I would go in order to stay.
My Web site finally went live early this year. I had it professionally designed, but I didn’t use a therapist-branding firm. In writing my own copy, I used Roth’s idea of “connecting questions” and went shamelessly casual, even though originally I envisioned a more formal tone and less personal information. I had no idea how well received it would be by potential clients. After all, I studied mental illness, not marketing.
This may not be true for the next crop of therapists. Marie Miville, chairwoman of the Department of Counseling and Clinical Psychology at Teachers College, Columbia University, told me that graduate schools have begun adding marketing to their curriculums. Despite a deep discomfort around the commercial aspect of the work, she said, therapists are learning how to supplement their practices. Susan Giurleo suggests using what she calls passive income streams like workbooks, tip sheets and other products that can be sold online. She also makes video workshops on, say, homework survival, selling them for $50 for an eight-week course, along with a workbook. Others have loosened up the 50-minute session frame by offering 20-minute sessions to give as many options as possible.
Part of me felt hopeful that I wouldn’t have to resort to all this. People were slowly finding me through my Web site, and that, I thought, would be enough to sustain me. But the thing about branding is that it feels never-ending. For every concession I made, I hadn’t gone far enough. Web site? Check. Personal disclosure? Check. Consulting services? Check. But when I called Stephanie Smith, a psychologist and the public education coordinator for the A.P.A. in Colorado, she told me that in a therapist-glutted market like mine, I should increase my social-media presence. She said that she decided to differentiate herself in the saturated Denver market by branding herself “not as a therapist stuck in the mind but as somebody who’s in touch with what’s going on in the regular world of pop culture.” She blogs after episodes of “Glee,” posts about movies she likes and tweets about the Denver Broncos. “This way,” she explained, “people see that I’m a normal person, too.”
But there was more: Casey Truffo told me that in order to diversify, I should also offer instant-messaging therapy and even cited its clinical merit. “A therapist might say some brilliant things in the therapy room that the client will forget in half an hour,” she explained, “but now the client can read it over and over.” She also said text work, as she called it, “can make therapy deeper in the way that people who meet on Facebook reveal more because of the anonymity.”
I’ve never seen research on the efficacy of text therapy, but one study on phone-versus-in-person cognitive-behavioral therapy for depression showed that while people stuck it out longer with teletherapy, largely because of accessibility and convenience, they showed less improvement six months later than those in face-to-face therapy. It’s not surprising that many clinicians practicing psychotherapy, which involves the interplay of numerous relational elements — the subtle movement of an eyebrow, the unconscious shaking of a foot, the smile while recounting a painful story — question how well it works remotely.
It’s precisely this double bind in which many of my colleagues and I feel caught. If we give modern consumers the efficiency and convenience they want, we also have to silence our nagging sense that we may be pandering to our patients rather than helping them. Will we do therapy in 140 characters or less, or will we stick to our beliefs but get a second job to put food on the table? It’s one thing to be more than a blank slate and even to focus on finding solutions, but will we throw away so many doctrines of our training that we cease being therapists entirely? The more we continue in this direction of fast-food therapy — something that feels good but isn’t as good for you; something palatable without a lot of substance — the more tempted many of us will be to indulge.
The field has evolved since Freud said that the goal of psychoanalysis was to convert neurotic misery into ordinary unhappiness, but it’s not that far from what most therapists still do. I hate to think that therapy is an outdated idea, too slow and too private to satisfy a population that has come to expect immediate responses and constant gratification. The truth is, I’m just a person trained to sit in a room and — if I’m really doing my job well and am attuned to all the subtle suggestions and gestures at play in an ongoing, face-to-face therapeutic relationship — help people understand themselves better so they can live more fulfilling lives. When I shared this description with ShrinkWr@p’s Alison Roth, she laughed out loud: “Not sexy!” she said. She wasn’t surprised to hear that I still have spots open for referrals.
Lori Gottlieb is the author, most recently, of ‘‘Marry Him: The Case for Settling for Mr. Good Enough.’’
Editor: Ilena Silverman
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