This is an important argument, one that I'm more than happy to restack and share it with others. In fact, I made a similar point, if only briefly, this morning in another forum.
But similar "dual relationships" also occur in individual private practice (even if we don't call them that). The patient's needs may not align with the clinician's preferred treatment modality. The therapist's economic interests may sway treatment recommendations.
The real difference in corporate practice is not the existence of clashing aims—those are inevitable—but the substitution of business ethics for professional ethics.
The ethics of the helping professions is fiduciary: to put the patient or client first despite countervailing incentives. In contrast, business ethics are not inherently fiduciary; they're ultimately about earning profit any way that is legal. Ultimately, it is incumbent on clinicians and our professional organizations to uphold our own ethical standards. Institutions will not do that for us.
I agree with this take. There are always incentives operating.
In corporate settings (including non-profit), macro-level decision making shifts from individual clinicians to executives and administrators, and the balance of forces tends to shift toward a business frame of reference.
Thank you for making this distinction, although I wonder to what extent "business ethics" is an intelligible term anymore. The recognition they are not "inherently fiduciary" leaves one to wonder whether there is any identifiable ethical purchase to speak of. As you do in your posts, and Dr. Shedler does here, something is terribly amiss within the therapeutic ranks, something akin to Cory Doctorow's "enshittification." The financialization of the field brings efficiency, standardization, and the drive to develop a therapeutic "brand" in the service of profitability, but flattens time, that precious gift needed to cultivate the kind of therapeutic relationship that fosters change. I wonder to what extent the celerity of this cultural moment, and the demands that align with it, impedes the kind of work espoused in Dr. Shedler's posts, as well as your own. Take care.
I have read Darragh's article on the "therapist as good enough object"and found it to be very insightful. Whether financialization is the primary cause I cannot say with absolute certainty, but working the field I see it is a significant factor. Reasonable minds can disagree. All the best.
Unfortunately, when we do uphold our own ethical standards, we face punishment from these institutions and entities (e.g., insurance companies, corporations, VC-backed firms). Perhaps I'm splitting here, but it seems that there is a clear choice we have to make in this setting: earn a paycheck and keep your head down, or stand firm on ethical principles and refuse to compromise on quality patient care. I may end up with a steep decrease in my income, but that's a chance I'm willing to take at this point. I may eat my words later, but I would rather earn less and know that I did everything in my power NOT to harm other human beings.
There are those who work within systems to reform them, and those who cannot work in such systems. I'm in the latter category, and certainly understand the sentiment. Like you, I aim never to compromise on quality patient care. But I very much respect those who struggle within such systems, since they serve the needs of patients who will never come to my office. I have rather less respect for those who DON'T struggle...
One way that helps me provide care to those clients dependent on the system (Medicaid in my case) is to be transparent about the bureaucratic demands that shape the therapy as a psychodynamic stance. I wrote about it here:
I'd rather address the conflicts (frequent Tx plan reviews, using measures to track progress, limiting session frequency, etc.) overtly and become an ally for the client by acknowledging what is restricting both of us in serving the them.
I appreciate this sentiment. Even in the recent past, I was within the former category and thought that - just as the slogan goes - "giving back to the community." Soon, though, one realizes that many of those same organizations that claim to "give back" to their communities end up doing harm because of policies designed to maximize profit and squeeze as much low-wage labor out of practicum students, interns, and pre-licensed clinicians as possible. It's just not right. It sounds like we are veering toward the same decision of creating change with patience, perhaps just one tiny morsel at a time. Maybe that's enough.
It really is a damn shame what has happened to this field. I can speak to the compromised care and the dual relationships I've witnessed in private equity backed mental health businesses. Ridiculous volume expectations with minimal supervision that's mostly administrative work for charting. Guidance for treatment comes in the form of PDF with a flowchart of 'best practice options' and links to online trainings for the most proven evidence based therapies.
Thanks for this. The point about institutions necessarily representing a dual relationship is particularly poignant.
I wonder about this, though: You seem to imply that “We cannot provide the kind of care here that would be most helpful for you. This is what we can provide for you here, given the resources we have and the constraints we work under. But it is not optimal care for you" would be the kind of sentiment that might help ease the shame of a difficult/high-needs/pick-your-euphemism patient who is not helped in an institutional setting. I disagree. I don't think it's possible to avoid making a difficult patient feel ashamed, if neediness/too-much-ness is the kind of thing that would make him feel ashamed. A softer euphemism for "you are too much for what we can offer" will not take the bite out of that bitter truth.
I think, per the thesis of your article, that the only way to ease the shame of a difficult patient is to work in depth with him and let him find out that needing a lot (being difficult) is not the same thing as being bad.
I don’t think my argument applies primarily to “difficult” patients. In institutional settings, business considerations often push all patients toward the briefest, cheapest treatments. Open-ended psychotherapy (or any psychotherapy) tends to drop of the menu for everyone.
I often tell people that I give them the best I can, given the constraints. Because they can’t get anything better anywhere else, I assumed it wasn’t helping, but this is a nice way of seeing it.
Having worked in corporate healthcare before entering private practice, I have seen many of these dynamics firsthand. Productivity measures, RVUs, scheduling demands, insurance denial reports, lean staffing, and growing caseloads often influenced care across disciplines, not just psychotherapy. Decisions were often made from the top down with little clinical input. Most clinicians wanted to provide good care while practicing within significant constraints.
I hadn’t thought of dual relationships in this way before, and I think it helps express that conflict we feel in this work. I remember in my first year out I was attending a workshop on a comprehensive multidisciplinary treatment for first episode psychosis (a truly excellent program) and my question to the facilitators was ‘what are the guidelines for working with FEP with our current resources, because this model sounds amazing, but we don’t have resources to implement anything near that?’ The answer was something along the lines of ‘just do your best’, which wasn’t particularly helpful, but then again, it probably wasn’t a fair question to ask them. Until (unless) this conflict between what we know is best treatment and what we can provide is resolved, we really need to be preparing future clinicians how to navigate this. I grapple with this more than I do with issues around limits of confidentiality and out of session communication.
I have been having this ongoing conversation with my partner as I navigate a transition into private practice. I keep asking myself, "Is this really what I completed 8 years of school for? Is this it?" I am becoming more jaded and find myself moving away from the field, and it really comes down to whether I am willing to compromise my own values for a paycheck to survive, or to tolerate the bullshit these larger firms constantly peddle to us. I really don't see a way out.
Such precise and well-articulated diagnosis, thanks Jonathan. Sadly, I don't think this is contained to psychotherapy in institutional settings only. Many institutions have administrative and financial agendas that often don't align with the best interests of individuals who rely on them, and those who work inside them. The NHS here in the UK, and delivery of physical medical care, suffers from some of what you have described too. Nurses are leaving in record numbers because they are burning out at unprecedented rates, made to work in conditions that prioritise budgets over all else. However, it's incredibly sad when people seek therapy, get what most professionals know is insufficient to actually help them, and leave thinking, 'I am too broken to be helped'.
Jonathan I wonder if you have heard anything about similarities or differences within the UK psychotherapy field as our service is free at the point of service. We still have demands from services and KPIs which need to be satisfied within services like IAPT, now called talking therapies.
"Do what makes you happy" she said. "Should I get high?" - "yes". And she had a LCSW. Just tell everyone to be happy, get happy, think positively, assume good intentions.
The problem of compromised care within a context of distinct interests presents ethical issues that clinicians accustomed to trying to fit in may not even recognize as requiring consideration. This is because we live in a world in which run-of-the-mill success is built upon compromise. A blindness to it accompanies the tacit acceptance that one 'follow the leader' on being accepted into whichever institution. One may unquestioningly accept the sanctity of the bottom line. When values are malleable, the insidiousness of the process of compromise prevails.
This is an important argument, one that I'm more than happy to restack and share it with others. In fact, I made a similar point, if only briefly, this morning in another forum.
But similar "dual relationships" also occur in individual private practice (even if we don't call them that). The patient's needs may not align with the clinician's preferred treatment modality. The therapist's economic interests may sway treatment recommendations.
The real difference in corporate practice is not the existence of clashing aims—those are inevitable—but the substitution of business ethics for professional ethics.
The ethics of the helping professions is fiduciary: to put the patient or client first despite countervailing incentives. In contrast, business ethics are not inherently fiduciary; they're ultimately about earning profit any way that is legal. Ultimately, it is incumbent on clinicians and our professional organizations to uphold our own ethical standards. Institutions will not do that for us.
I agree with this take. There are always incentives operating.
In corporate settings (including non-profit), macro-level decision making shifts from individual clinicians to executives and administrators, and the balance of forces tends to shift toward a business frame of reference.
Thank you for making this distinction, although I wonder to what extent "business ethics" is an intelligible term anymore. The recognition they are not "inherently fiduciary" leaves one to wonder whether there is any identifiable ethical purchase to speak of. As you do in your posts, and Dr. Shedler does here, something is terribly amiss within the therapeutic ranks, something akin to Cory Doctorow's "enshittification." The financialization of the field brings efficiency, standardization, and the drive to develop a therapeutic "brand" in the service of profitability, but flattens time, that precious gift needed to cultivate the kind of therapeutic relationship that fosters change. I wonder to what extent the celerity of this cultural moment, and the demands that align with it, impedes the kind of work espoused in Dr. Shedler's posts, as well as your own. Take care.
I agree there's enshittification in my field, not uniformly of course. And yes, it clearly impedes the kind of work espoused by Dr. Shedler and me. But I don't believe financialization is the primary cause. Instead I'd refer you to this article by Darragh Sheehan, which for me states the dynamics as carefully as anything I've seen: https://everydayinquiry.substack.com/p/the-therapist-as-the-good-enough?r=346o1x&utm_campaign=post-expanded-share&utm_medium=web
Thank you for sharing this post! I have been gnawing on this idea for years and I can see in the first few paragraphs this will be a good one :)
I have read Darragh's article on the "therapist as good enough object"and found it to be very insightful. Whether financialization is the primary cause I cannot say with absolute certainty, but working the field I see it is a significant factor. Reasonable minds can disagree. All the best.
Unfortunately, when we do uphold our own ethical standards, we face punishment from these institutions and entities (e.g., insurance companies, corporations, VC-backed firms). Perhaps I'm splitting here, but it seems that there is a clear choice we have to make in this setting: earn a paycheck and keep your head down, or stand firm on ethical principles and refuse to compromise on quality patient care. I may end up with a steep decrease in my income, but that's a chance I'm willing to take at this point. I may eat my words later, but I would rather earn less and know that I did everything in my power NOT to harm other human beings.
There are those who work within systems to reform them, and those who cannot work in such systems. I'm in the latter category, and certainly understand the sentiment. Like you, I aim never to compromise on quality patient care. But I very much respect those who struggle within such systems, since they serve the needs of patients who will never come to my office. I have rather less respect for those who DON'T struggle...
One way that helps me provide care to those clients dependent on the system (Medicaid in my case) is to be transparent about the bureaucratic demands that shape the therapy as a psychodynamic stance. I wrote about it here:
https://www.psychotherapynetworker.org/article/how-rote-admin-requirements-can-actually-deepen-therapy/?srsltid=AfmBOorDeq6G4Mwo--PG-TX9ObFjf9bdtn5Pt4NyYe-5AoXxT5JgTAuc
I'd rather address the conflicts (frequent Tx plan reviews, using measures to track progress, limiting session frequency, etc.) overtly and become an ally for the client by acknowledging what is restricting both of us in serving the them.
I appreciate this sentiment. Even in the recent past, I was within the former category and thought that - just as the slogan goes - "giving back to the community." Soon, though, one realizes that many of those same organizations that claim to "give back" to their communities end up doing harm because of policies designed to maximize profit and squeeze as much low-wage labor out of practicum students, interns, and pre-licensed clinicians as possible. It's just not right. It sounds like we are veering toward the same decision of creating change with patience, perhaps just one tiny morsel at a time. Maybe that's enough.
It really is a damn shame what has happened to this field. I can speak to the compromised care and the dual relationships I've witnessed in private equity backed mental health businesses. Ridiculous volume expectations with minimal supervision that's mostly administrative work for charting. Guidance for treatment comes in the form of PDF with a flowchart of 'best practice options' and links to online trainings for the most proven evidence based therapies.
Definitely.
Quite grim, indeed.
Thanks for this. The point about institutions necessarily representing a dual relationship is particularly poignant.
I wonder about this, though: You seem to imply that “We cannot provide the kind of care here that would be most helpful for you. This is what we can provide for you here, given the resources we have and the constraints we work under. But it is not optimal care for you" would be the kind of sentiment that might help ease the shame of a difficult/high-needs/pick-your-euphemism patient who is not helped in an institutional setting. I disagree. I don't think it's possible to avoid making a difficult patient feel ashamed, if neediness/too-much-ness is the kind of thing that would make him feel ashamed. A softer euphemism for "you are too much for what we can offer" will not take the bite out of that bitter truth.
I think, per the thesis of your article, that the only way to ease the shame of a difficult patient is to work in depth with him and let him find out that needing a lot (being difficult) is not the same thing as being bad.
Thanks again for the article.
I don’t think my argument applies primarily to “difficult” patients. In institutional settings, business considerations often push all patients toward the briefest, cheapest treatments. Open-ended psychotherapy (or any psychotherapy) tends to drop of the menu for everyone.
Excellent reminder.
I often tell people that I give them the best I can, given the constraints. Because they can’t get anything better anywhere else, I assumed it wasn’t helping, but this is a nice way of seeing it.
Having worked in corporate healthcare before entering private practice, I have seen many of these dynamics firsthand. Productivity measures, RVUs, scheduling demands, insurance denial reports, lean staffing, and growing caseloads often influenced care across disciplines, not just psychotherapy. Decisions were often made from the top down with little clinical input. Most clinicians wanted to provide good care while practicing within significant constraints.
Yup.
I hadn’t thought of dual relationships in this way before, and I think it helps express that conflict we feel in this work. I remember in my first year out I was attending a workshop on a comprehensive multidisciplinary treatment for first episode psychosis (a truly excellent program) and my question to the facilitators was ‘what are the guidelines for working with FEP with our current resources, because this model sounds amazing, but we don’t have resources to implement anything near that?’ The answer was something along the lines of ‘just do your best’, which wasn’t particularly helpful, but then again, it probably wasn’t a fair question to ask them. Until (unless) this conflict between what we know is best treatment and what we can provide is resolved, we really need to be preparing future clinicians how to navigate this. I grapple with this more than I do with issues around limits of confidentiality and out of session communication.
I have been having this ongoing conversation with my partner as I navigate a transition into private practice. I keep asking myself, "Is this really what I completed 8 years of school for? Is this it?" I am becoming more jaded and find myself moving away from the field, and it really comes down to whether I am willing to compromise my own values for a paycheck to survive, or to tolerate the bullshit these larger firms constantly peddle to us. I really don't see a way out.
Such precise and well-articulated diagnosis, thanks Jonathan. Sadly, I don't think this is contained to psychotherapy in institutional settings only. Many institutions have administrative and financial agendas that often don't align with the best interests of individuals who rely on them, and those who work inside them. The NHS here in the UK, and delivery of physical medical care, suffers from some of what you have described too. Nurses are leaving in record numbers because they are burning out at unprecedented rates, made to work in conditions that prioritise budgets over all else. However, it's incredibly sad when people seek therapy, get what most professionals know is insufficient to actually help them, and leave thinking, 'I am too broken to be helped'.
Thank you for adding this.
Jonathan I wonder if you have heard anything about similarities or differences within the UK psychotherapy field as our service is free at the point of service. We still have demands from services and KPIs which need to be satisfied within services like IAPT, now called talking therapies.
I think this take is very relevant to NHS Talking Therapies
I think I would agree Tim!
"Do what makes you happy" she said. "Should I get high?" - "yes". And she had a LCSW. Just tell everyone to be happy, get happy, think positively, assume good intentions.
“Do what makes you happy” is a bumper sticker slogan, not psychotherapy.
don't get me started on "therapy mills"
The problem of compromised care within a context of distinct interests presents ethical issues that clinicians accustomed to trying to fit in may not even recognize as requiring consideration. This is because we live in a world in which run-of-the-mill success is built upon compromise. A blindness to it accompanies the tacit acceptance that one 'follow the leader' on being accepted into whichever institution. One may unquestioningly accept the sanctity of the bottom line. When values are malleable, the insidiousness of the process of compromise prevails.