I worked for ten-and-a-half years as a psychotherapist, nine of them licensed and one-and-a-half as a social work intern. For the last four years I have worked as a filmmaker. I have considered of late turning in my therapy license (an LCSW), and, if I were to return to the psychological helping profession, to do so as a life coach—unlicensed and outside the system. But is this wise? Others often ask me similar questions for their own career paths, and I realize the subject is complex. In the spirit of this, I wish to compare and contrast the two, from a variety of angles.
Therapists have one, coaches don’t—or at least most coaches don’t. This of course makes it a lot easier to call oneself a coach, which is a great advantage, though it simultaneously throws open the door to wild cowboy practitioners and quacks. For these reasons, people tend to trust licensed practitioners more, even if that trust is not always, or even often, warranted. After all, the mental health field has an endless supply of licensed quacks. But at least when someone has a license there is standard of care you can expect from them. The problem is, what if many of those standards are themselves warped?
Standards of Care
One of the reasons I would like to give up my therapy license is that I do not believe in many of the standards of care of the modern mental health field. I don’t believe in pushing psych meds on people, especially vulnerable people in serious turmoil—those with so-called “biological diagnoses”—as per the modern dictums. Licensed practitioners who do not do this are considered substandard care providers and leave themselves vulnerable to all sorts of professional and legal liability. Another farcical standard of care involves forcing hospitalization or police on people who are supposedly a danger to themselves or others. What about focusing on building real healing relationships instead? And, of course, what about confidentiality here? Alas, confidentiality is only a lesser respected standard of care, which I find atrocious, because in many cases it makes therapists into agents of the state, not agents of their clients or agents of healing. Many therapists—the really good ones—secretly rebel against these standards and don’t practice them, but life coaches don’t have to get caught up in this nonsense at all. On the other hand, I could imagine the laws of the land arguing that a coach has no business seeing such “troubled” clients and penalizing him or her for unlicensed practice of psychotherapy. Coaches seem to be expected to work more with “mild” cases. But this is a farce, because in many ways therapists, especially in private practice, are also expected to turn away “the serious cases” too—and refer them to hospitals or hospital-based clinics to get drugged, or, if they’re less lucky, drugged and locked up too. What the state and the majority of the mental heath field fail to recognize, however, are the incredible numbers of people who had the most serious diagnoses and who got the most psychological help—real help, real nurturance, real interpersonal commitment, real insight—from people who weren’t even professionals at all. And many got this help from no one at all except themselves—from within.
Code of Ethics
One thing people often value about therapists is that they follow a code of ethics for personal behavior. I pretty much respect the therapeutic codes of ethics, but, at the same time, see them as pretty obvious and logical for any healing practitioner with a conscience, licensed or not. Coaches, meanwhile, are not required to follow any code of ethics except their own inner code and the law of the land, whatever that might be. To be honest, I in many ways prefer the inner code, because it allows the inner bell of truth to rule, not some list voted on by a bunch of questionable people I never met. However, this inner code might easily be exploited by coaches with less than stellar internalized ethics, allowing them to run hog-wild in taking emotional, financial, or even sexual advantage of clients. Yet therapists can and often do easily do the same. That said, clients working with licensed therapists, not coaches, have one advantage: they have more, though often still limited, recourse for reporting ethical breaches to formal licensing bodies.
Becoming a therapist requires a lot of training, and a lot of this is bullshit—endless bureaucratic hoops, classes that can be limited or pointless or misguided, less-than-stellar or even sadistic supervisors, and a lot of expense and debt for all this “privilege.” Coaches have the advantage of being able to avoid all this and learn their trade in a much freer and more creative environment of their own making. Ultimately, though, both coaches and therapists must get the same real “training” to become good at their craft: interacting with real people in real life situations to gain real life experience. There is no substitute for that. That said, one advantage to being a therapist is that if you do your training within the system you can get referrals more easily than can most new coaches who’ve just hung out a shingle. On the other hand, if you’re a new coach with a good personal reputation or a really good private referral network, you can probably get more referrals than most new therapists in the system.
I really don’t see a big difference here. I know several life coaches who charge more than many therapists, and I know several therapists who charge five times more than I ever charged any clients. I think high fees are one of the biggest frauds of the psychological helping profession. In general (though not always) what I have observed is that the better clinicians, be they coaches or therapists, charge LESS money, not more. They have has a deep caring for others and don’t want to exploit—and instead want to make their work as accessible as possible. But personally I think most everyone, therapist or coach, charges too much. Our society, unfortunately, encourages this.
In many places, therapists are required to diagnose everyone who walks into their office. As a licensed clinical social worker in New York City, I was required to do this and I didn’t like it. It’s a main reason I would not want to work as a licensed practitioner again. For starters, the diagnoses are arbitrary and not scientifically valid—having been voted on by a small group of psychiatrists who are too often entangled with the drug companies. Additionally, I have never seen a person have his or her emotional growth process enhanced by getting labeled with “Borderline Personality Disorder” or “Schizophrenia” or “Bipolar Disorder” or “OCD” or “Generalized Anxiety Disorder.” On the contrary, diagnoses tend to be disempowering, stigmatizing, and harmful—and, at best, do nothing to assist a talented therapist in helping catalyze personal growth. Instead, diagnosing gets in the way of the real work, and in many cases, especially with new therapists, seriously distracts from it. It’s scary how much people believe in these diagnoses. Coaches, thankfully, operate entirely outside of the diagnostic system. For them, diagnosis is neither necessary, nor, in fact, even allowed. But personally I think every clinician I have ever met, therapist or coach, licensed or not, DOES have some sort of diagnostic skill, in the deeper meaning of “diagnosis”: to figure out what is ailing or conflicting a person seeking help. It’s just that good clinicians don’t waste their time using simplistic psychiatric labels and instead use more human and nuanced ideas. For instance, instead of affixing the label of “Recurrent Major Depression” onto someone, they might see that the person has been extremely emotionally stuck, sad, and hopeless for a long time regarding issues of his childhood or adult trauma, and also that that trauma and the person’s replications of it have been impeding him in moving forward with his adult relationships, his self-development, and perhaps his work. This kind of diagnosis, if you want to call it that, can really provide a clinician—and a client—a real framework within which to work. And these kinds of “diagnoses” are useable by anyone—anyone, that is, with insight and creativity and humanity.
Billing Insurance Companies
Therapists, especially if they have several years of experience and a good license, can do this, and this can save clients a lot of money. However, these days more and more insurance companies are cutting costs and thus making it harder for therapists to bill them. The companies increase pointless paperwork, increase clients’ copays, reduce the number of session available per year, purposefully keep limited stables of therapists, decrease overall payments to clinicians, and often require therapists to engage in major lapses of client confidentiality not just to get paid but to justify, ludicrously, the “medical necessity for treatment.” Also, because insurance companies try to avoid payment for “less serious” therapeutic cases, therapists can feel pressured to fabricate more serious diagnoses for clients in order to insure payment, and I have no doubt that many less ethical therapists succumb to the temptation. This can potentially come back to bite clients in any number of way. Coaches, on the other hand, cannot bill insurance companies—at least none that I have heard of. More and more I see this as an advantage, and so do some therapists I respect, who no longer bill insurance companies and instead charge clients what they can realistically afford to pay.
Power within the Mental Health System
Therapists, to varying degrees, have it. From the minute they become interns they certainly have the power to harm—to hospitalize people, to pressure them to take psych meds, etc.—but also the power to help people within the system: to help them find housing, connect with certain services and even moneys, and navigate the psychiatric hospital system in order to break free of psychiatry. Therapists can also help clients by liaising on their behalf with other mental health workers, such as psychiatrists or nurse practitioners, who are helping them taper off psych drugs. Personally I found this power a valuable use of my therapeutic license, and if I returned to practice as a life coach I would miss it. Life coaches, on the other hand, are generally not taken too seriously, if taken seriously at all, within the system. I don’t see this as entirely bad, though. One thing I like about the idea of coaching is that it is a job that is unplugged from the system. This allows the focus of the work to stay right where I find it most valuable: on personal growth.
Quality of Service Provided
I think there is no definitive way to determine the quality of a clinician simply based on his role as a therapist or life coach. It’s the same thing with the letters after someone’s name, such as PsyD, LCSW, LPC, PhD, MD, or LMFT, to name a few: I find them meaningless as indicators of therapeutic quality, and too often just a marker of the clinician’s ego. Ultimately, I think the best way to determine the quality of the clinician is to get to know the quality of the person behind the role: his or her degree of maturity, altruism, compassion, empathy, wisdom, depth, experience, flexibility, commitment, creativity, humor, intelligence, and generosity. Few clinicians, be they coach or therapist, score really highly in many of these categories, though in my opinion all should. That, in part, is why I prefer therapists and coaches who are very public and detailed about their point of view. This not only shows their courage in being themselves publicly, but also gives potential clients an opportunity to see who they’re dealing with.
Ultimately I don’t have a good answer to this problem about which profession is better. I see advantages and disadvantages to both. Ultimately, though, I think that any good life coach is a good therapist, and any good therapist is a good life coach. So ultimately, perhaps, this whole essay is just a reflection of the insanity, fragmentation, and obsession with labeling and categorizing of our mental health system, or mental illness system, depending on your point of view.
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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.