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New Success Symbols Rise as Private Practice Therapy Fades
It is time to stop encouraging therapists to aspire to big careers in private practice. The problem is less the work than the aspiration itself. Private practice is a cultural ideal, a symbol of success, not just a way to earn a living. Clinicians commonly see it as the height of a career. As professionals, they have expectations of autonomy, prestige, and affluence. Private practice embodies those dreams.
The idea of such a practice is more resilient than its reality. Careers are increasingly falling short of expectations due to the economics of healthcare. Self-employment has been on the decline throughout the healthcare industry. Private practitioners are turning to salaried work. Yet the cultural ideal survives, especially in our field. No wonder—our field has been the quintessential cottage industry.
Business consolidation has been driving 21st century healthcare. News headlines tout the merger and acquisition activities of ever-larger corporations, and we now see consolidation across previously separate categories of insurers, facilities, and professional groups. We cannot understand our field without grasping major tectonic shifts in the larger healthcare landscape.
One shift getting little attention is especially relevant for behavioral clinicians. Physicians are becoming employees of integrated healthcare corporations. Employed MDs are now the supermajority:
Nearly three-quarters of US physicians (74%) are employed by hospitals, health systems, or corporate entities as of January 1, 2022, according to new data from Avalere in a study sponsored by the Physicians Advocacy Institute (PAI) that examined physician practice trends over the 3-year period between 2019 and 2021.
This development has predictive value for psychotherapists. As behavioral services are steadily acquired by health systems, their employment status will mirror that of physicians. While some MDs are content with their salaried status, many older physicians pine for the golden age of private practice. They surely experienced such an age. Therapists have had mostly brief and intermittent golden years.
The Unfortunate Grip of Private Practice
Consider the physician experience. Primary care physicians (PCPs) have long enjoyed professional lives marked by autonomy, prestige, and affluence, even though earning less than medical specialists. Psychiatrists still enjoy this role more than most MDs because many of them work outside the insurance-based healthcare system. Some non-MD therapists have enjoyed this role too, but it has been aspirational for most.
Private practice therapy is a cultural icon, and it is alluring. Therapists want to reach this pinnacle of professional practice, but many have to settle for small practices while employed elsewhere. The problem is that this ideal has always been at odds with third-party insurance reimbursement. Funding has been more of a hurdle than fuel for private practice. Success has demanded grit and luck.
Our field’s insurance history replicates (but lags) medical milestones. Health maintenance organizations (HMOs) and managed care for physical health preceded our management efforts. Similarly, our field has lagged in terms of healthcare consolidation and the testing of new forms of risk contracting like value-based care. However, our funding has always been a small fraction of medical spending. Clinicians have been competing for too few dollars.
Freud introduced the “talking cure” over 100 years ago. Psychoanalysis helped shape the private practice paradigm, and Freud’s iconic couch has outlived many of his clinical ideas. Private therapy is unaffordable for most clients, and yet therapists still eagerly hang out shingles. Let us retire the couch and the shingle as icons. They mostly fuel frustration and unrealistic expectations.
New Symbols of Success and Equitable Pay
The allure of private practice will fade as the healthcare economy changes, but this is not the end of professional aspirations. New icons are needed to motivate therapists working in healthcare companies. The path may be different, but professionals still desire autonomy, prestige, and affluence. How will they achieve these goals working in the healthcare system?
Our orienting focus might be that therapists take pride in improving our healthcare system. If that is the focus, we may need to find a way to iconize our role as champions of the biopsychosocial model. This may seem intangible, but therapists can thrive by not only treating behavioral conditions but also by addressing comorbidities and the way behavior broadly impacts health and illness.
Autonomy may be threatened by some wanting to mandate structured, manualized therapies, but there are strong counterarguments promoting clinical judgment and measurement-based care. Compensation is a critical aspect of professional pride, and salary equity is achievable. Therapy positions should be treated as comparable to those held by advanced medical practitioners (e.g., nurse practitioners & physician assistants).
While private practice will surely survive to some degree for wealthy consumers, it is counterproductive to give it much attention or prestige. Therapists should be tied less to a place of service because in the future they will probably work in many settings. The anchor should be the biopsychosocial care model.
Cultural ideas and symbols matter. Private practice iconography is self-defeating today. Executives can help break its grip as we transition to the consolidated world of healthcare. New symbols of success are as important as equitable pay. Therapists must collaborate with business executives to realize these goals. We are entering a new era with unique clinical and business demands.
Ed Jones, PhD is currently with ERJ Consulting, LLC and previously served as president at ValueOptions and chief clinical officer at PacifiCare Behavioral Health.
The views expressed in Perspectives are solely those of the author and do not necessarily reflect the views of Behavioral Healthcare Executive, the Psychiatry & Behavioral Health Learning Network, or other Network authors. Perspectives entries are not medical advice.
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