Setting up your own practice, & giving back to the community: An interview with Dr. Alan (Part 3)
Dr. Alan has grown a successful psychotherapy practice over his 27 years of work, but also actively worked to provide lower-cost psychotherapy services to the community. He has founded and teaches regularly at Rose City Centre, a community clinic that offers psychodynamic psychotherapy on a sliding scale, as well as offering structured supervision and work opportunities for beginning therapists. He currently runs this with a team of colleagues and a manager, while devoting most of his days to working with clients in his private psychotherapy practice.As a therapist finding my feet in India, I am fascinated by all these aspects: establishing a personal practice and an institution, building a network of dedicated professionals and community outreach. So, in the third part of this series, I talk to him about building a private practice, setting up Rose City Centre and raising money from funders for long term low cost psychotherapy.
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AB - How was it initially, to take the decision to be a psychotherapist and work to build your private practice?
AK - Well. I initially had decided to be a medical doctor, as my father and grandfather were both doctors. But I was also studying philosophy and I fell so in love with philosophy that I drifted away from the sciences a bit. I had decided to become a psychologist. I applied to graduate programs and went to one in LA which was very practical, hands-on. Two of the most painful courses were when we actually had to see a patient but were being watched through a one way mirror by our colleagues and then we’d get together and talk about it, critique each other’s work.I began working in a couple of different clinics for internships and that’s where I learned about forensic psychology, and I spent some years working with psychiatrists. But I decided to leave when the psychiatrist made some changes that meant I would effectively be getting a 30% cut. I still remember the day exactly.
It was 23rd December 1988 and by the first of January, 1989 I had rented my own office, and I had about 20 patients and touch wood, they all came with me. Then I frenetically took people out to lunch, called doctors and lawyers, told all my friends. I probably bought two different people lunch, every single week!
And well, the other thing I did was to join professional organizations, the like the American Psychological Association and go to their meetings because that’s another way you meet people. And then I also began writing, and I also began teaching right away. So that helps get your name out. And for those of you who are starting out, I understand that it’s very scary and I was lucky to have those 20 patients, but even if you have 5 patients, pretty soon you have 7, then 10, and within 4-5 years you can’t see any more. So that’s the story of how I went into my own practice. The other thing I would add is that I’ve always liked seeing couples and families and I had some training in that but I didn’t really plan on having half my practice as couples, it just evolved that way. And I think a lot of you and your colleagues will find the same thing. And that’s how my practice grew and it’s been going pretty well all these years. I can afford a trip to India, as long as I deduct from taxes!And here's Dr. Alan with his prized collection of Freud's entire works!
AB - Tell us about how you began Rose City Centre. There must have been so much detailed effort involved in conceptualizing, planning, getting permissions, creating a team and keeping them on board- how did all of this happen for you?
AK - About 20 years ago was when I first began making a good enough living as a psychologist. I was able to save money, pay my bills. I was able to realize that I would be able to pay for my kids college education and then I very quickly became guilty because uh, I wasn’t doing anything to help poor people. So I developed this idea for a clinic that would be devoted to poor people. And it was very easy to find colleagues who were interested in helping me.
Because I don’t know how it is in India, but if you want to talk just blunt dollars, finding a good, competent psychoanalyst in LA it will be $175-$200 per session. That’s a LOT of money. And if you have a single mother who works as a schoolteacher, there is no way she will be able to afford that!
So the thing that my colleagues came to help me with was that we all felt guilty because there was no such place for affordable therapy in Los Angeles. Because if you go to a hospital, they’re going to put you into a hospital. And if you go to a government clinic they will give you less than 5 therapy sessions and they’re really going to push medication on you. So it’s very very difficult to get good lower cost psychotherapy on a consistent basis if you are struggling financially.So, I very wisely brought someone onto the “little committee” for Rose City Centre who was an MBA. Because starting out we were all psychotherapists; we didn’t know anything about business! In fact I have a funny story to tell where the very first director (Kathleen) of Rose City got angry at me and quit and we had to really quickly had to find a replacement. And so when we had the board meeting, the businessman was a friend of mine so I told him, “Well, I guess we should talk about what happened with Kathleen.” And my friend Bob, the businessman, said “Alan, this is NOT group therapy! We don’t talk about our feelings here. We need to make a decision about how we are going to find a new Executive Director.”
So you see, a very important part when you are setting up a clinic like this is to realize that it’s a business, like a shoe shop.
You could be selling dog food. You have to have insurance, office space and part of how we are able to offer the low fees is that we have student therapists. They are excellent. And so we started with one clinician 11 years ago, and then they moved out of the state and then we had zero. Now we have 10. They get paid 1/3 of the patient fees, the 2/3rd goes to Rose City and 50% of our operating budget comes from patient fees. The other half comes from donations and grants. We write grants to any number of foundations who are interested in providing long term therapy. The other thing is that we don’t accept any government insurance or aid because we don’t want anyone interfering with the privacy of the patient-therapist relationship. The fees are as low as $25 and if you can pay more than $85 then we usually refer them out to another private therapist. Rose City Centre is my proudest professional accomplishment. Like even though I have 2 PhDs and everything (yes, I’m masochistic like that!), it was also the greatest therapy for this guilt because it went away. Because although I don’t particularly want to work for a $35 fee anymore, I am on the board of directors and I also teach there every Friday for free. And probably 100 psychoanalytic therapists are or have been involved with Rose City centre in some way. We have a waiting list of therapists who want to come join the team and a waiting list of clients who want therapy. And also the class I teach on Fridays with a colleague of mine.
We’ve developed a 2 year curriculum of psychoanalytic psychotherapy and we have 12, two-month modules from the history of psychoanalysis to transference, and analytic theory.
AB - How was it to translate this to a group of people who were deciding whether or not to fund you? What was the process like?
AK - So firstly, as this group of practitioners who were interested in creating Rose City Centre, we began meeting. And we began to develop almost a narrative of what psychoanalytic psychotherapy is and how it’s different than CBT or medication. And so there were two nonprofits that really helped us out. One is called Community Partners, and they are a non-profit incubator. They don’t give you money but they help with facilities and raising donations through them. They took 9%. That really helped us. We all pitched in $1000 each, and we got our families, our friends, even our dogs to pitch in too!And that allowed us to get a grant writer who wrote a grant to the California Wellness Foundation. And they were interested in our idea of providing long term therapy but in a private practice setting.
So the clinic doesn’t look like run down, free clinic in a bad neighborhood. It looks very nice.
We like the idea of that, and we explained to them that if you have someone who has a foundational conflict then that would be an example where the psychoanalytic approaches are the best. We somehow miraculously convinced them.
I remember being very excited when they flew one of their staff down from San Francisco to meet with us, because I thought “well, if they’re going to blow this much money on a plane ticket, then!”
They gave us $50,000 for a grant which was actually the biggest grant we’ve ever gotten. That allowed us to find an office space, to open an office, to hire an intern, and in the past 12 years, we’ve gone from 1 intern to 10 interns. Our operating budget is now about $300,000 a year.
AB - Can you tell me a bit more about how you build and support a team of good clinicians who are willing to offer low cost psychotherapy?
AK - Yes. We have pre-doctoral internships and post-doctoral internships for therapists, who are in training. All of them are required to commit 20 hours a week to the clinic for two years, and they are trained further by our team, during that period. Since one cannot make a living from 1/3 of low cost therapy fees, the good thing about Rose City is that when the contract is over, all therapists are allowed to take their clients with them.
So we’ve had a lot of therapists who work at Rose City for 2 years, get 15-20 clients and then begin their own private practice keeping those 20 clients.
AB - So in that sense, it is also an incubator for beginning therapists.
AK - Incubator is the perfect word! Yes.
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“You know Arpita, Rose City Centre is my proudest professional accomplishment.” These words stay in my head, long after the interview is done. I understand why.As therapists, for most of us, the dream is of connection. We spend years teaching ourselves to understand more deeply, observe more keenly, and connect more fully with our clients. We continue to hold the threads of more narratives, and we grow roots in our consulting rooms. Still, the dream of our work is about creating connection, and we root it into our consulting rooms. I wonder about what it would look like if we found ways to branch out, and start doing small things to build a more mental health friendly culture, and spaces that can engage with individuals and families, therapeutically. I wonder what it would look like, if every city, every state had a place where people in distress could walk in, and trust to be really listened to, for as long as they needed it, and to know they could afford low cost and high quality therapy. What would it be like to share this dream of connection out loud, with everyone who also has the same dream? What would the branches look like?
This is the third of a three part series that documents my interview with Dr. Alan Karbelnig. Part 1 focuses on talking about therapy in a therapeutic setting, and Part 2 focuses on therapists and the practice of psychotherapy.
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