Psychotherapy’s Image Problem Pushes Some Therapists to Become ‘Brands’

Illustration by Matt Dorfman. Photograph by Jens Mortensen for The New York Times.

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.' "

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