Practice: On Overselling Psychotherapy

Not quite enough, unfortunately.

Like any professional group, psychotherapists have wanted to have their work appreciated and acknowledged within the larger community. Part of this motivation is financial: without public awareness of what we have to offer, we will have no clients and quickly go bankrupt. Part of it is altruistic: we cannot help those who do not come to see us.

But it isn’t enough just to say “I’m here.” We have to say what we can do, what the likely benefits are, and how much it will cost. And suddenly the door opens to a series of cognitive biases and self-serving statements that can distort the message.

The marketplace wants to know that our product works, and that it is worth the price tag. There are two ways to make this balancing act seem to come out in our favour:

1. Overstate the likely benefits, perhaps by guaranteeing results (which would be great and appropriate if we could actually do this, but we can’t) or inflating expectations.
2. Underestimate costs, by providing cost estimates based on rapid responders rather than typical cases, and by playing a psychotherapeutic variant of Name That Tune (“I can cure that problem in just X sessions”).

Both of these problems are widespread in the field. We regularly hear about revolutionary new treatments that promise enormous benefits to every client, but that never seem to live up to the hype. The eventual effect is a justified skepticism among referral sources, particularly when the next psychological panacea comes along. The attempt to raise the profile and prestige of the field has the unintended opposite effect.

And we ourselves can collude with hopeful referrers/funders by underestimating the number of sessions that will be necessary for a prospective referral. We want to have a reputation for quick, no-nonsense work (no lolling about on couches for decades with us!), we genuinely hope to be rapidly effective, and prospective cases almost always sound more straightforward than they turn out to be. The referrer wants to minimize costs and speed up the client’s recovery. Both parties are motivated to arrive at an unrealistically brief estimate of the time therapy will take.

The distorting effect can gradually take on ludicrous proportions, and many referrers now reside permanently in Fantasyland. I routinely get phone calls from insurers calling about treatment-resistant claimants who have been off work three years or more, who have complicated and ongoing presentations (with comorbidities ranging from addiction to cancer), and inquiring whether I might take them on for, say, five sessions?

For years I didn’t quite know how to respond to these requests, but in retrospect the answer is simple and obvious, and it is the one I now employ. “No, thank you.” It is inappropriate to establish a therapeutic relationship with a client that will be severed prematurely.

How else can we overcome the hopeful bias in psychotherapy referrals?

1. Face the fear that referrals will dry up, and base your initial estimate of the number of sessions required on a cold-eyed assessment of the genuine average number of meetings for cases a bit more complex than the one on offer (given that this one will inevitably turn out to be more complex anyway).  
2. We should refrain from statements about our effectiveness with clients we have never met. Even if we are very enthusiastic about our methods, we should be circumspect about the likelihood of improvement. “Yes, this is found to be effective with some cases, but I will have to learn much more about the client’s situation…”
3. Hide your enthusiasm under a bushel. Let your results sell your practice, not your promises.
4. Aim to come in beneath your estimated number of sessions, rather than trying to “make a good start” and then hoping for extensions.

And, of course:

5. Just say no. “I would be delighted to be able to get this person back to work in three weeks, but I’m afraid I’m not willing to take on the case without a commitment for more time.”

What if honesty and humility mean that we don’t get enough referrals? Well: that's life.

*   *   *

Want more information on operating a private psychotherapy practice?

Check out my book Private Practice Made Simple, available at bookstores and through Amazon here.

Vancouver Workshop November 29 2013

Click here for information and registration for the one-day workshop Private Practice Made Simple being held in Vancouver Canada Friday November 29.