Following the Money

Why fewer and fewer men are becoming therapists.

Ilene Philipson
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From the March/April 1994 issue

WHEN I ENTERED GRADUATE SCHOOL IN CLINICAL PSYCHOLOGY in the late 1980s, after 15 years as a sociologist and teacher, I had no idea that I was preparing myself for a world that no longer existed. I thought I’d get my Ph.D., continue to write, and support myself comfortably in private practice, like friends who had hung out shingles a decade before. Along with thousands of my fellow graduate students, I was oblivious to the bigger picture: hordes of us mostly women were pouring into a glutted market, and the statistics were telling a curious, rarely discussed tale about the relationship between gender and the dollar.

It boils down to this: The worse things get economically for psychotherapists, the more women enter the field and the more men stay away. It started in the mid-1970s, at the very beginning of what became the therapy glut. Between 1975 and 1985, as the vast population bulge of the baby boom went through graduate school, the  number of psychotherapists more than doubled. According to statistics kept by the professional organizations, psychiatrists increased their numbers by 46 percent, clinical psychologists by 80 percent, social workers by 140 percent, and marriage and family counselors by an astounding 367 percent. Increasingly, the newcomers were women, entering a profession whose edges had already quietly begun to fray.

Did men have more sensitive antennae for the economic changes ahead? In the 1980s, the numbers of male Ph.D. candidates in clinical psychology dropped by two percent per year. By 1992,62 percent of the nation’s 1,300 new clinical psychology Ph.D.s were women, compared to 31 percent in 1976. Today, 42 percent of the 118,000 members of the American Psychological Association are female, compared to 27 percent in 1977.

Even the traditionally female (and less well-paid) field of social work has become more heavily female: 76 percent of the 120,000 members of the National Association of Social Workers are now women, up from 72 percent in 1988. Sixty percent of the American Association for Marriage and Family Therapy’s 20,000 members are female. Even psychiatry is changing: in 1979, women were 31 percent of all psychiatric residents; by 1993, they were 44 percent.

If the grim news about managed competition is filtering down the educational pipeline at all, it doesn’t seem to be having much effect. My alma mater, the Wright Institute, a freestanding school of professional psychology in Berkeley, has 400 applicants for 40 openings next year. The average age of the applicants is 37, and 72 percent of them are women.

Why are women continuing to train themselves for an economically declining field while men are quietly walking away? Do women think less about money and more about meaningful work? Do men worry more about being breadwinners? Do they have wider career choices? If our work is seen as “women’s work,” will we lose even more clout? Whatever the answers are, we need to talk openly about them.

ONE THING IS CLEAR: MEN FORM a declining proportion of the newcomers to the field. At workshops, leading family therapists say, eight out of ten trainees are usually women. “Men have a way of bailing out of lower-status occupations into more lucrative professions,” says Nicholas Cummings, the founder of American Biodyne, the nation’s first and largest mental health managed care company.

Some men choose other work because they fear psychotherapy is losing status and won’t provide adequate pay. “When my father went to graduate school, being a clinical psychologist was an unusual thing; it was the 1950s, and he got lots of job offers,” one man told me, explaining why he chose medical school over psychology two years ago. “It’s different now much harder to find a job.”

“Men seem to follow the money,” says Dorothy Cantor, a psychologist in private practice in Westfield, New Jersey, and chair of the APA task force on the changing gender composition of psychology. “As managed care comes in, men are not going into psychology. They’re going into the business world, and into engineering and computer software places where they can be more autonomous. By 2004, the APA will become predominantly female. Once that happens, will the men really stay away in droves?”

If a recent study of members of other occupations that have feminized (like pharmacists, typesetters, secretaries and banktellers) is any indication, there is a real danger that within a decade, psychotherapy will be completely dominated by women. Rutgers University sociologist Pat Roos says it’s not that the mere presence of women causes an occupation to decline, but that declining occupations become less attractive to men, and women, with fewer job options than men, take their place.

“When occupations begin to deteriorate, men perceive that they will no longer provide them with the same opportunities, and they leave,” says Roos, coauthor, with Barbara Reskin, of Job Queues, Gender Queues, a recent study of feminizing occupations. “But women see that the earnings are better than in traditionally female jobs, and they look at these jobs as opportunities.”

Typesetting, pharmacy, secretarial work and banktelling, for example, were once relatively well-paid, autonomous and predominantly male occupations, Roos says. Then, technological and economic changes set in, wages dropped and the work was simplified, feminized and declined in status. Unionized male linotype jobs disappeared when newspapers modernized and printing presses moved overseas. In their place came typesetting jobs in electronic printing and photocopying houses, employing non-unionized women at far lower wages. In the 1970s and 1980s, neighborhood pharmacies were driven out of business by drugstore chains, and the pharmacist became a hired hand who counted out pills. When pay and status declined, men stopped going to pharmacy school, and women, for whom pharmacy work still paid better than traditionally female jobs, took their place.

Is psychotherapy going the same way? In the 1970s, psychotherapy was an attractive choice for women. It drew on the emotional skills most women absorb from birth, and it promised far better pay and autonomy than teaching, nursing and other traditional forms of “women’s work.” Because private practice is a small business, it seemed to present fewer institutional barriers to women than business or law. And it promised the flexibility to accommodate women’s continuing responsibilities for households and children.

We didn’t realize just how flexible those schedules would turn out to be. Managed competition hit, our appointment books have huge blank spaces, and still women continue to pour into the field. As the years go by, and older male psychotherapists retire, the therapist who opens the office door will more and more likely be a woman.

If the profession of psychotherapy “tips” like a once-integrated neighborhood that becomes identified as black we will probably join the women’s job ghetto, where our political leverage, pay and autonomy will decline even further. Once psychotherapy is seen as a woman’s job, men will probably avoid it even more strenuously because of the stigma attached to men who cross the hidden gender boundaries in the work world. “Ask a group of women to think about ‘my daughter the doctor’ and everyone smiles,” warns Cantor, who was a schoolteacher before retraining as a psychologist. “Ask them to think about ‘my son, the nurse,’ and you get a completely different response.”

In entry-level psychotherapy, the future has already arrived. Women form the bulk of the newest, least-established clinicians. We are the last hired and first fired; we hold most of the worst-paid jobs in the field. Ever since I first went to work as a psychology intern, I’ve noticed a pattern: an army of underpaid women, often serving under the direction of older, better-paid men, are on the front lines of a field devastated by funding cutbacks and insurance reorganization.

In one wealthy northern California suburb, the director keeps his family services agency going by paying his mostly female interns nothing and his mostly female staff therapists $16 an hour. In an urban crisis clinic that ministers to the homeless, the psychotic and the suicidal, one paid therapist per shift supervises the work of three to ten unpaid graduate students most of them women. In a managed care clinic in Massachusetts, women with Ph.D.s who are waiting for their licenses earn $9 an hour seeing clients in closely supervised, short-term therapy. Power is distributed along gender lines: the supervisors are men, and so are the clinic’s three cofounders.

This pattern fits with what Roos and Reskin found in the “feminizing” occupations they studied. When formerly male occupations open up like real estate sales, bus driving and newspaper reporting women usually are concentrated in the least-desired jobs within them, because employers still prefer to hire and promote white men. Women, for example, work as school-bus drivers, while men are more likely to drive city buses; women are more likely to be real estate salespeople, and less likely to be brokers.

Even in the less formal world of psychotherapy, some of the same principles apply. According to surveys by Psychotherapy Finances newsletter, women psychotherapists charge about $5 less per session than men, and are more likely to offer treatment on a sliding scale. Full-time, male psychologists earned a median income of $81,818 in 1992, while women earned $62,500. Male marriage and family counselors earned a median of’$61,538, and women earned $47,419.

Part of this guff may result from women’s acculturation. “I think there’s the expectation that women are going to care naturally and be more generous,” says Elana Katz, coordinator of on-site training at the Ackerman Institute for Family Therapy in New York City. “I hear my female students say, ‘I’m just starting out, I’ll charge less.’ I haven’t heard that from the men.”

But much of the difference results from society’s pervasive, subtle, gender bias, from which psychotherapy is not immune.

“My observation of agency life is that while few people would espouse gender bias, there must be some subtle favoritism because men seem to move into positions of leadership in agencies more fluidly than women do,” says David Dan, a social worker and director of a community mental health center in Philadelphia, who just hired his first female psychiatrist. “For some reason, people are more comfortable with men in leadership in ways that they might not acknowledge.”

So men remain a privileged minority in better-paying jobs as clinic directors, managed-care supervisors and even as hands-on clinicians. Dan, for example, worked as a hospital-based social worker at Queens Child Guidance Center in New York in the 1970s. “It was unionized by local 1199, the hospital-workers’ union, and there were male line staff making decent salaries,” he remembers. “Where you have unions, and good benefits, you have more male social workers.”

At the same time, the growing scarcity of men in the field increases the leverage of the men who remain. “The lack of men in the field is actually great for business,” says Patrick Dougherty, who is in private practice in St. Paul, Minnesota. “I have clients lined up at the door. I work with successful white men, and once they’re clear they need something, they’ll pay whatever they need to get it.”

Family therapists have always been pretty savvy about the influence of the political and economic context on their clients’ lives; now it’s time we think and talk more openly about their influence on our lives as well. The current solutions offered to our economic problems are competitive and individualistic. Marketers tell us that only the strong will survive the shakeout, that we need to pound the pavement, elbow one another aside, get aggressive, develop a niche, hire someone to write a snazzy brochure.

When women turn to their own (often female) therapists, they are likely to ask equally individualistic questions about their fear of success, guilt about competence, desire to fail, or anxiety over being more successful than their parents. I don’t think this is an issue to be psychoanalytical about; women need to acknowledge that they are dealing with a real, widespread social phenomenon.

But we don’t. Even in the highly political Bay Area, where I live, money is the last taboo. We just don’t talk about it, afraid, perhaps, that our colleagues will see us as failures. In my local alternative newspaper, classified ads from therapists fill three pages. But my women psychotherapists’ discussion group met for two years without talking openly about how business was going, even when one of us, in a tacit admission of financial trouble, began working as a bookkeeper for other psychotherapists.

Other women tell me privately that they think of moving to South Dakota; some continue to work part-time at their previous occupations as real estate agents or physical therapists. Some women I knew in graduate school have told me privately that they are carrying more than $80,000 in educational debts and earning $35,000 a year reviewing flies for managed care companies. Others see a handful of clients in living rooms or converted attics. Recent graduates can’t even join the lists of preferred providers who see clients for managed care organizations at discounted rates; in the Bay Area, the referral panels are filled and closed.

The numbers tell us that no matter how brilliantly we market ourselves, not all of us will make it. I know one 45-year-old woman in Los Angeles who spent thousands of dollars on brochures and marketing experts as she tried to establish a practice over the past two years. She’s declaring bankruptcy this month. Those of us who are forced to retool and do other work don’t need to hear that it was our own fault.

Women must begin to come out of the closet and talk about these professional issues in a political context. And not only talk, but act. We need to look at systemic solutions at decreasing the number of freestanding professional schools that are churning out debt-ridden graduates for whom there is no work, at organizing to improve working conditions for those of us who remain. Perhaps managed care workers men and women will someday be unionized, like hospital-based social workers were. Perhaps we will form guilds, like the American Society of Magazine Photographers or the Authors’ Guild, to negotiate with insurance companies and set minimum pay. Perhaps some of us, and our clients, will become active in our communities and help build a culture where the work of emotional healing is respected and rewarded once again. In any case, if we demystify the issues and bring them into a wider community, we can see our circumstances more realistically, as bigger than our own failures.

Women have tremendous power within the field of psychotherapy. We set the terms of much of the debate. Fifteen years ago, when men dominated the field, childhood sexual abuse, wife-beating, sexual exploitation by therapists and the interlocking influences of gender and power were all soft-pedaled. No more. Within the therapy room, even the relationship between client and therapist has been feminized. No longer does a therapist look down on a client: both parties are on a more equal footing. In psychodynamic therapy, gone are the days when male clinicians, from on high,  told a patient why she was the way she was, as in traditional psychoanalysis. Far more popular now are the egalitarian models of interpersonal and self-psychology, in which the therapist admits mistakes, and the responses of both therapist and client are held equally to the light. In family therapy, the scientific, hierarchical, emotionally removed styles of men like Jay Haley, Salvador Minuchin and Carl Whitaker no longer predominate. “The original family therapists were a bunch of bull elephants,” Says David Treadway, a family therapist in private practice in Weston, Massachusetts. “Today, family therapy is located within traditional female values collegiality, intimacy and mutual validation. The things that women tend to do well with each other are now seen as the way to do family therapy. It’s almost uncouth to say one’s a strategic therapist these days.”

But if the male perspective is lost entirely from our profession, the culture will once again see emotional work as women’s work, and I think we all will lose. If psychotherapy becomes a women’s enterprise, will male clients be even more reluctant to come in the door?

In my clinical practice, I see many people in their twenties who have had no male figures in their lives who were kind, nurturing and caring and benign. They are the products of single-mother households and of divorce; they remember hostile stepfathers, or simply no male at all. And, now, that societal wound, that abandonment, is being increasingly replicated within psychotherapy itself.

As I listen to these young people, I think how unlikely it is that they will ever be able to tell their story to a caring male therapist. This is one more reason why we need to act together. If we don’t, the men will continue to bail out for software and law and Wall Street. And psychotherapy will continue to move rapidly into the undervalued and underfunded shadows of public life, the place where underpaid women nurses, teachers, social workers, mothers and now psychotherapists have always done the work of emotional caring and healing.

Ilene Philipson, PhD, is a clinical psychologist at Pacific Applied Psychology Associates and in private practice in Berkeley, CA. She is the author of On the Shoulders of Women: The Feminization of Psychotherapy (Guilford Press) from which this article is adapted. Consulting Editor Katy Butler also contributed to this article.