Many Happy Returns

It may be a coincidence, but when I turned 40 I began to hear the term ROI a lot. For those of you who may not have heard of ROI, it stands for “return on investment.” There is a technical definition of it on Investopedia, but I think I figured out why it kept leaping to my attention last week when I was speaking to someone about dragging my feet on a piece of work I had committed to do.

“I’m just worried that this will be a waste of time.” I was talking about return on investment.

I have always been a worrier about time, and like Marvell always hear Time’s Winged Chariot. But it has usually been from a fear-based perspective, and somehow, ROI has gotten me thinking more about finitude from a more positive perspective. Yes, there is a limited amount of time in my life, so what am I going to do with it? Am I going to spend it angsting about the ever-decreasing amount of it, or am I going to embrace my agency and be mindful of how I am investing myself in life? My colleague, psychologist Susan Giurleo is an excellent power of example for this. We both have psychotherapy and consultation practices, and have watched as health insurers have begun to put the squeeze on providers while continuing to enjoy their own salaries stability. I have become a founding member of AMHP, a group of mental health providers who are becoming activists about this issue. When I asked Susan if she would post an entry on our group discussion she was ambivalent about it, and in her explanation of why she was ambivalent she wrote:

1. I think major efforts will generate a low ROI. We can fight a cut, but

the nation is heading toward insuring more people for less money. Writing is

on the wall for all health care, not just mental health.

2. I’ve found putting my energies into diversifying my income stream has

huge ROI. I’m working toward a business model where I don’t take insurance

because I want to be paid for everything I do at the time of service.

Accepting managed care is just a bad business plan for so many reasons. I’d

rather slide my fee and get the money in hand than have to bill and haggle

with a third party.

There was that phrase again, ROI! Susan’s point makes good business sense, but it also makes good life sense. And the beauty of it is that each of us get to evaluate ROI for ourselves! I can wholeheartedly understand her point of view, and at the same time find that investing my time and effort into AMHP brings returns for me that I find very valuable. I have already begun to meet more of my local colleagues throughout my work on this. I actually enjoy reading about antitrust laws, and discussing this and the business side of my practice. I find political activism very rewarding, and get more energized to research and advocate for AMHP. It has me talking more with colleagues about another interest of mine, working with therapists to make better use of technology like social media. We live in an historic moment in that never before has it been so easy to share so much information with so many mental health providers across the world so quickly! This has been utilized by the health insurance industry to our detriment, but it is accessible to us. And not just in fighting the good fight against managed care. Technology can bring great ROI on our practice. I have used Skype to conduct psychotherapy in Asia, and have supervisees who “beam in” regularly for their appointments. And if you don’t have a website, if you don’t “invest” yourself in the internet, I am convinced that you will see diminishing returns in your practice.

As therapists we invest in our work, and more importantly we ask that our patients invest in it as well. But therapy should never be an act of completely blind faith for a patient, they can and should consider what the ROI will be on the hours and dollars spent. We have an obligation to be able to explain why the work is worth investing in. And we need to get more comfortable with the idea of ROI, because if we don’t define our ROI the insurance companies will. They already have: the briefer the treatment needed to get symptoms reduced to a least common denominator, the better the ROI. As one clinical reviewer at UBH told me last week when I said that a patient’s GAF of 70 was their highest the past year: “Well we need to look at the fact that this is probably their baseline and end treatment.” Oh, really? I guess I should just say to them, “sorry, you can’t become any more insightful, have greater well-being according to UBH. You’ve plateaued at ‘meh,’ so don’t let the door hit you on the way out. My solution to this problem is to say to UBH, sorry, not enough ROI for me, I’m out of your network. Will I need to work harder in other areas to generate revenue? Yes. But will I ultimately have a better quality of life without having to play such profane games, you betcha. Thinking in terms of ROI has made me more confident, more thoughtful about what I take on for work, and what I pass by.

So let me know, what brings you your highest ROI in your work, your life? What brings the lowest? When that car cuts you off, what is the ROI on teaching them a lesson with your horn or finger? When you feel a sense of presence and accomplishment with a therapy’s deep work, remind yourself that you are experiencing a moment of mindfulness. Mindfulness of ROI. Don’t miss it, and when you notice opportunities for ROI act on them, because as Jack’s mother in “Into the Woods” says, “opportunity is not a lengthy visitor.”

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