Psychotherapy Bulletin

Psychotherapy Bulletin

Psychotherapy Practice over the Lifespan

As members of the Professional Practice Committee of the Society for the Advancement of Psychotherapy, we are tasked with meeting the needs of private practitioners. In our monthly meetings, we noted how the needs and experiences of practitioners change as one matures into the role of a psychotherapist. Since our committee has a diverse combination of members from different developmental stages, we thought it would be useful to survey our small committee about these needs and experiences. The results of the survey identified some of the challenges, opportunities, and issues and concerns confronting therapists at these different stages of practice. The nine participants consisted of three Late Career (more than 20 years practice), two Middle Career (10-20 years), and four Early Career (less than 10 years) who completed a Google Form survey in September 2023. Each participant was asked what they saw as the challenges, opportunities, and unique concerns related to their respective stages of development. Below is a summary of our findings. As you read through these findings, we encourage you to reflect on your current stage of practice and consider the challenges and opportunities relevant to you at this time. 

Profession Practice Challenges

Our early-career practitioners expressed challenges in balancing family and work, while growing one’s practice “simultaneously.” One participant expressed difficulties “balancing financial pressures of student loan debt” while struggling to “meet the needs of clients served.” Another participant, still in graduate school, talked about struggling with all the expectations of graduate school, engaging in “diverse scholarly work on top of intensive clinical training” while not being paid, or paid very little, for the internships.  

Mid-career participants mention finding a balance in their work and personal lives. For example, “balancing demanding day to day practice responsibilities with other valuable and desirable professional activities such as continuing education, teaching, presenting, volunteering, committee involvement,” as well as building a practice and having “clients that can pay” the participant’s fee.  

Late-career participants reflected on the challenge of eventually retiring; what that would look like, the practicalities related to slowly reducing caseloads, and developing professional wills. In addition, one participant mentioned feelings of loss and isolation due to “colleagues dying or becoming seriously ill (Alzheimer’s, stroke etc.).” Balancing life priorities with practice priorities were also mentioned as a challenge along with shifting their focus to self-care and recognizing one’s “time is limited” and wanting to make the best of the time they had left personally and professionally.  

Professional Practice Opportunities

Early and mid-career participants expressed a need for support and mentorship, but generally felt it was available. While late-career participants felt they had expertise to share, including gained wisdom and opportunities to mentor. Nearly all participants reported appreciating being involved with other professionals in the field and working in many different capacities as a psychotherapist. 

More specifically, early-career participants identified planning for “longevity” which involved having a “professional plan” thinking that one would have years ahead to continue working. This also involved looking for opportunities “to continue to learn and hone my craft clinically and also make long term business plans.” One participant talked about the variety of “professional opportunities and autonomy” available at this stage. Another participant mentioned having “robust opportunities” to deeply learn research, practice, and teaching. This idea was expanded by a participant who talked about the “opportunity to be involved with other professionals in organizations...acquiring mentorship and feedback from mid-level to late career psychologists” to help find “my footing in the field.” Opportunities with diverse mentors helped another participant learn to do “great work” while “navigating the systemic hurdles that mental health professionals face.” 

Mid-career participants noted opportunities for “connections with other therapists,” having the opportunity to create a solid referral base, and being able to share “professional knowledge, mentorship, and guidance based on my expertise.” 

Late-career participants talked about feeling they were able to be “better clinicians” in part by feeling more calm and less stressed from challenges during the earlier part of their career. One participant noted having gained “wisdom about certain client issues and about life” and feeling like she had “a unique opportunity to share with others what I have learned in my long life and my long experience working with clients.” This was echoed by another participant who talked about appreciating opportunities to “mentor and supervise young clinicians” and noted her increased competence about “therapy, life, and about running a business.” This participant also mentioned the benefits of having a referral base from a “word-of-mouth reputation.” Like another participant at this stage, she noted that she had become “a more effective writer, speaker, teacher, trainer, consultant and advocate.” 

Issues or Concerns Unique to Each Stage of Professional Practice

Themes in this area differed by stage with early career participants having concerns about money and career path decisions, while mid-career participants were dealing with issues of burnout and income. In contrast, late career participants noted issues around generativity, retirement, closing a practice, staying relevant, and more focus on personal interest areas reflected in the clients they work with.  

Early-career participants talked about balancing priorities in terms of starting a family, building financial security and the growing needs for mental health clinicians. Being able to prioritize training needs with time for family and maintaining a financially secure client load were touted as issues. In addition, one participant felt graduate school had not provided adequate preparation on opening a private practice while one prepares to pay back student loans. Another participant talked about “the most unique challenge to this stage is associated with the rising student loan debt burden and navigating through those difficulties.” Another very early career participant noted concerns around “[making] career decisions but having limited time to reflect on their career issues given the high workload” as a trainee.  

Mid-career participants were mostly concerned with avoiding “burnout” and having enough income. 

Late-career participants wondered about issues such as creating “a professional will” as well as “when and how to retire” and “how to share your wisdom.” Participants talked about how things had changed since beginning their careers and the need to manage the “generational cultural gap.” Still, they felt that with time and experience, they had become more effective therapists.    

In our last set of questions, we asked specific questions targeted to each practice stage. The questions and some of their responses are below.  

What did early-career participants want to ask of mid to late career psychotherapists? Responses indicated these participants needed guidance on career path options, managing finances and debt, and on doing the work long-term in a sustainable way. Echoing responses from earlier in the survey, they were curious about the “necessary components to achieving longevity in this field that help to make it a sustainable career given the draining and underpaid work of being a practitioner.” These participants also wondered about financial strategies related to high student loan debt and having a living wage. They also expressed interest in how one decides to go down the private practice career path, and to know more about “how to” develop a private practice as a viable business.  

Mid-career participants shared one thing they were glad they did or wished they had done when starting their practice. Participants noted the value of networking and the importance of professional self-esteem. “I’m glad I went all in making connections and participating in non-income generating activities which I think all grew my referral base” and “I wish I had valued myself more and had more insight as to how to do what I see colleagues do.”  

Late-career participants shared what they wished they had known earlier related to growing and maintaining a professional practice. Participants generally wished they had more information and support to focus on building a practice. One participant wished that she had “been a bit more intentional in developing my practice” including spending more time formally or informally talking to others who were also building a practice. Similarly, another participant mentioned wishing “I had met with a lawyer earlier in my career to set up a different type of business (LLC) that may have been easier on taxes and would have been easier to bring other therapists into my practice.” Finally, another participant talked about wishing she had started her practice sooner and noted feeling “intimidated by the idea of running my own business.” She thought that she “needed to know everything and didn’t realize that she “could continue to figure it out” after she got started. 

​​ ​​​Discussion ​​​​

In reflecting on our surveyresults, we noted that our participants expressed concerns about finances and balancing life priorities across all the different stages. Other researchers have examined developmental stages of psychotherapists. For example, Skovoholt and Rønnestad (1992) developed a Lifespan Development Model and Orlinksy and Rønnestad’s (2005) example how psychotherapists develop. It was interesting to us, in reflecting on these other excellent resources, that these models did not focus as much as our participants did on concerns about finances and balancing life priorities at different stages. 

It seems for our participants that the practical and financial issues involved in practice-building are not given enough attention in training. As one participant remarked, “these questions… made me aware of the gaps in training for psychotherapists.” In addition to having to acquire a unique set of business skills, there is considerable financial risk involved in establishing a private practice. The psychotherapist needs to have the resources to invest in space, utilities, marketing, equipment, wages, subscriptions, supplies, insurances, licenses, and other unplanned expenses. This might be particularly true for those living in single income households, for those starting new families, and/or those who are carrying huge student loan debts.  

Based on our survey responses it appeared that new practitioners without pre-existing financial resources were not able to afford the startup costs involved in setting up an office, or the time required to build it. A perspective represented by our survey participants was that building a practice around the demands of a full-time job and starting a young family was financially, physically, and emotionally difficult. Some respondents named “income” and “burnout” as their main concerns. One respondent commented on the low insurance reimbursement rates and   questioned “how to navigate high student loan debt in higher cost of living areas.”  

Although the survey responses related to financial concerns represent those of many, if not most, psychotherapists across the practice lifespan, they highlight the importance of addressing systemic issues that create unique financial barriers to Black, Indigenous and People of Color (BIPOC) psychotherapists at all stages of practice. One BIPOC respondent clearly noted the negative impact of “the structural barriers that exist within the field.” According to Helen Park, licensed therapist and fellow at the Ackerman Institute for the Family, “The cost of post-graduate training opportunities, and preparation for licensing is …a challenging hurdle for aspiring BIPOC therapists.” Park went on to say that “…the pressing need for therapists of color is only amplified by the systemic issues that prevent them from breaking into the field in the first place” (Onque, 2022). 

The sharp increase in racial and ethnically motivated hate crimes and the myriad of social, political, and economic stresses impacting BIPOC communities have led to an exponentially increased demand for culturally competent services. Given this need, and the growing changes in the face of the profession, it is prudent to consider how to actively deconstruct these barriers. Dr. Whitfield at North Carolina ATT State University suggests recruiting more students and faculty from marginalized groups (Whitfield, 2021). Park sees that private practices can contribute to the deconstruction, by actively seeking to hire aspiring BIPOC therapists into their group and offering them justifiable compensation (Onque, 2022). 

This survey was a quick sampling of the experiences of psychotherapists in private practice across the stages of practice. While our work is cursory, the general themes and concerns that emerged may be representative of the challenges and opportunities faced by other psychotherapists. Hopefully our work here has helped you to reflect on the concerns as well as potential opportunities we may encounter as psychotherapists and to help inform the education and training of psychotherapists.  

Acknowledgements:

Michelle Joaquin, Ph.D. 

Tameeza Samji, Ph. D. 

Cordaris Butler. MS 

David Friedman, PsyD 

Rosemary Adam-Terem, PhD 

Mira An, BA  

Cite This Article

Jackson, G. D., Vivino, B. L., Thompson, B. J., Jackson-Wolf, J. (2003). Psychotherapy Practice over the Lifespan. Psychotherapy Bulletin, 58(4), 40-44.

References

Onque, R. (2022, September 28). Increased demand and burnout are driving many BIPOC therapists to ‘the breaking point’. CNBC Make It. https://cnb.cx/3rgpdJK  

Orlinsky, D. E., & Rønnestad, M. H. (2005). How psychotherapists develop: A study of therapeutic work and professional growth. Washington, DC: American Psychological Association. https:/doi.org/10.1037/11157- 000  

Skovholt, A., & Ronnestad, M. (1992). Themes in therapist and counselor development. Journal of Counseling and Development, 70, 505-515.  

Whitfield, P.B. (2021, September 16). African Americans and the reluctance to seek treatment. Counseling Today (publication of the American Counseling Association). https:// https://ct.counseling.org/2021/09/african-americans-and-the-reluctance-to-seek-treatment  

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