Senior Clinicians: How Are They Faring?
Hylene Dublin, MSW, CGP, FAGPA

"Conditions Turning Harsh for Psychotherapists," asserts a headline appearing in The Boston Globe on October 16, 1998. Detailed within the article are recent developments in the mental health field, which are adversely affecting mental health practitioners. These developments, the article continues, have resulted in one in five psychotherapists leaving the field and more than 70 percent of those remaining experiencing a severe decline in income. While this is not news to many of us, what be more newsworthy to AGPA readers is how these harsh conditions are affecting some of our own senior members as they struggle with the dual challenges of aging and maintaining professional practices in this complex time.

Ten known and highly regarded members of AGPA, representing the three primary mental health disciplines, shared their experiences for this article. Ages of the interviewees ranged from mid-60s to late 70s; there was an equal distribution of men and women. They represented a geographic spectrum of the United States, including New York, Washington, D.C., Massachusetts, Illinois, Texas, Oregon and California. The length of time in practice ranged from 23 to 52 years. Despite varying perspectives on their current practices, no one was contemplating complete retirement from all clinical and/or educational endeavors. For the purpose of enhancing candid responses, the interviewees were guaranteed confidentiality. 

Individual vignettes

A. has retired from administrative and teaching responsibilities which he has performed for approximately 50 years. He maintains a small private practice, but lack of visibility makes it difficult to maintain sufficient referrals. There have been no new treatment referrals within the past year. A. refuses managed care, except for a limited involvement with an employee assistance program, but A. will see individuals at reduced fees. A. sees managed care "as destructively limiting the appropriate forms and durations of treatment." A.'s therapy groups have ended due to insufficient referrals, as well as the amount of work involved. A. has done some consulting and teaching at reduced fees and needs a few more patients to supplement retirement income. Despite all this, A. feels that the situation would be more problematic if A. was not ready to retire. As A. approaches retirement, A. worries more about the future for patients and junior practitioners.

B., a psychoanalytically trained clinician, has experienced an extreme reduction in referrals in the past few years. This has resulted in the need to share office space. Medical problems have made the decrease in practice hours a necessity, but also a hardship. B. greatly laments the current stringent time limits placed on treatment, which he believes neglect patient needs entirely. B. acknowledges the extreme frustration experienced in dealing with insurance company personnel, "where one deals with different people each time, without being able to get a straight answer from anyone." B. is also concerned about the amount of information released to insurance companies without appropriate protection of confidentiality and highlights the fact that reports on Monica Lewinsky's sessions with two psychiatrists are now part of the Congressional Record.

In addition to sharing private practice space with other clinicians, a significant trend within the field, C. also functions as an independent contractor at a clinic setting two days per week. C. is on one large managed care panel, maintaining what C. describes as a "love/hate relationship" with the organization which administers it. With much time and energy devoted to cultivating relationships with referring personnel, C. has managed to maintain referrals. Until recently, the managed care organization has been responsive to C.'s requests for additional sessions. This year, however, C. notes much more interference by the managed care company, including a need to see more records and other patient data. There is also a move toward capitation for service. C. does not bemoan these shifts, in part, because of C.'s need to decrease professional time and attend to a spouse's health problems. C.'s treatment groups have become short-term and focused in response to pressures from managed care. However, members do maintain the opportunity to re-enlist for another 12-week period, and the break between sessions is refreshing to both the group members and to C. Although her groups appear to be more focused and goal directed, she believes much opportunity for self understanding based on process examination is lost.

With less emphasis on psychotherapy training and funding to support university educational programs, D. now concentrates on private practice almost exclusively. Because of D.'s extensive experience, as well as great local visibility from fundraising and other activities, D. has managed to maintain a very full, "ivory tower" practice with self-pay upper middle and upper class clientele. D. tried dealing with managed care for a brief period but now refuses to take new managed care patients "as the fee has been decreased to an unacceptable level." As recently as the time of the interview with D., the managed care company with which she had been working had limited the number of patient sessions to five. With the few insurance-covered patients remaining in D.'s practice, payment has been slower, and termination of coverage is frequently threatened. D. points to colleagues whose incomes have been cut by 50 percent, those who are unable to get coverage for any patients with personality disorders, and other clinicians who are consulting and supplementing their private practices in a variety of non-traditional ways. D., who previously had as many as nine psychotherapy groups, now has two, with totally self-pay membership. 

E. feels that seniors in the field with good reputations actually have the advantage at this historical moment in time. On the faculty of three training facilities, E. does more teaching than previously. Private practice has not changed much, except in the nature of patients seen. E. feels that the individuals coming into treatment are more character disordered than previously. E. reports an increase in income over the past 10 years and still continues with a long-term psychodynamic focus. While E. describes other senior clinicians who are struggling with the frustrations of dealing with insurance, E. does not accept third-party payment. E. strongly advocates that the profession actively "represents its values and fights managed care."

What are we to conclude about the current state of affairs from these few representative tales from our senior colleagues? There are, in fact, some particular advantages to being highly experiences and having demonstrated skills and developed reputations. This often proves advantageous in sustaining referrals and retaining more choice concerning the nature of ongoing clinical practice. It may be easier to retain an "ivory tower' or boutique practice. This may also be dependent, however, on the density of practitioners in the geographical area in which one practices, as well as the prevalence of managed care and other third-party plans. Additionally, opportunities for teaching, supervision, and consultation are more readily available to experienced and well-regarded clinicians. Many of the interviewees emphasized an increased educational focus at this stage in their careers. Private practice also provides senior people with the opportunity for gradually decreasing their professional responsibilities, and enables retirement to be a process rather than a one-time decision. Several noted the need to accommodate family and/or individual health changes within their professional schedules. Some have adjusted fairly successfully to negotiating with managed care, but are uncertain about what the future holds.

Senior clinicians are facing the same issues with managed care and third party payers, as well as other problems prevalent in the field, as are their younger colleagues. Most of the seniors interviewed have little to do with managed care. However, the current trends of decreasing fees, less income for more work, more reporting demands, less autonomy with more responsibility, disappearing practices, delayed payment, sicker patients, as well as a general disparagement of psychotherapy have made these difficult times for all.

Most interviewees were in agreement about the current factors affecting the field of psychotherapy in general and group psychotherapy in particular. Fewer patients are coming in for long-term treatment, as the managed care quick-fix philosophy has affected the public sector's treatment expectations. Medication (the "magic pill") is seen as the solution. More people are coming earlier for relationship, marital, and employment problems. In addition, more character disordered and troubled people are coming for therapy. More people in previously secure financial situations have become economically disadvantaged and often need to negotiate reduced fees. Group has been used by some as a more affordable form of treatment, allowing for easier self-pay. In summary, more troubled people with more serious problems, and concomitantly with greater limitations on the length of service that can be offered, are appearing for treatment.

Many interviewees expressed concerns about the National Registry which should be noted. They unanimously reported that the CGP has had no effect that they can see as yet. Most have obtained the credential to support the organization. A few were originally strong supporters of some sort of registry noting training and experience, but many are concerned about what they perceive as the minimal level of competence that is required for certification. One respondent argued that it is much too expensive for anyone on a fixed income to maintain his or her certification.

So, given their predicaments, what do our senior members want from AGPA? The interviewees expressed a desire that AGPA publicize "the real issues" in psychotherapy and not just attend to those relating to managed care, which they view as a "short-term bandwagon." It is hoped that AGPA take a firmer stand regarding what constitutes quality psychotherapy and work to counteract the disparaging views about psychotherapy that are being promulgated. It is also their wish that AGPA be more proactive in its advocacy to the public. There were requests for more conference/institute programs aimed at advanced clinicians. Price considerations for meeting attendance for people on fixed or reduced incomes were also requested. 

AGPA must recognize the importance of the need for a supportive, collegial environment in dealing with the problems of aging during a period of rapidly accelerating professional change. It is something that we group therapists can hopefully do well.

This article was published in the December 1998/January 1999 issue of The Group Circle.