The thought that came a little bit later, and then got very very stuck in my brain, was how I knew exactly how many conservative evangelical churches will address this event.

I grew up in those churches. By kindergarten, I knew my rightful place was in hell, unless I accepted Jesus as my savior. I know now how much of my attachment style and personality was shaped by perfectionism, shame, and theology. But it was all I knew.

I grew up, and I believed. Very genuinely. I was highly involved in church and youth groups and big Christian retreats and conferences and all the things. When I got college, I dove headfirst not into frat parties, but into an evangelical campus ministry. I spent several years very deep into things like discipleship groups, biblical commentaries, and lots and lots of evangelism as an adult. So when I say that I’ve been in a lot of sermons, I mean it. While not all of the faith communities I was involved in have gone the way of MAGA, many have.

So as for how conservative, evangelical churches are addressing these disasters, it’s generally one of two messages.

God’s judgment. This one is most easily co-opted when the people affected are not stereotypical white Christians. So it’s perfect for the country of Nepal, where 81.2% of the population identifies as Hindu. The messaging here is that they are experiencing God’s wrath or judgment for not believing in the Christian God, and perhaps this will wake them up.

More evidence of the imminent end times. Christians who believe in the Rapture, which many evangelicals and MAGA Christians do, have witnessed natural disasters and wars for decades and attributing them to signs that the apocalypse is coming. And they generally mean an apocalypse that literally resembles the book of Revelation, starting with said rapture. A few years ago, when fires devastated a Colorado community relatively close to my home, my aunt called me to check in, and literally called it a sign of the end times. The most insidious part of this theology is that those who believe it will willingly accept the incredible harm of things like genocide, ongoing wars, and accelerated climate change because they believe that it’s not only inevitable, but ultimately a good thing. In their minds, the rapture is the second coming of Christ, and that is worth everything.

Both of these perspectives fill me with both anger and deep grief now. I have said several times that the current administration has caused me to defend Jesus more than I have in a decade. I think that’s the grief. It’s painful to see the very people who taught me the Bible, particularly my own family, drift so far from the core teachings of Jesus so blindly. I don’t have a silver lining or an important lesson learned from all this. I don’t have any answers. And I’m not here to debate the validity of anyone’s faith, or lack thereof.

This is just me and where I’m at. It’s been a rough few week (years honestly) in terms of religious trauma triggers. I think I just needed to name it out loud and feel a little less crazy. And I hope to offer solidarity to anyone else who is at some point in a faith deconstruction journey, and resonates with my experience.

As always, thanks for reading.

Laura

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We are easy to fool.

I’m not talking about clients. I’m talking about pushy marketing, business coaches that look suspiciously like an MLM, shady recruiting tactics, scams, and peer pressure.

I think there are a few qualities about us overall that are not unique to therapists, but perhaps do apply more to therapists than the average professional.

We want to help people. Most of us don’t go into this field to make exorbitant amounts of money (LOL) or to exploit others. We start on this career path because we genuinely want to make others’ lives better. And that often comes with default behaviors, like giving people the benefit of the doubt, showing compassion, and staying curious. These are good and important qualities in our work. But these tendencies can lead to us ignoring red flags, because we’re trained to approach an odd situation with curiosity.

We also always need money. Therapists are chronically overworked and underpaid, regardless of whether they have a full time job at an organization or are self-employed. With constantly increasing inflation and economic instability, insurance reimbursement rates and salaries that never really increase, and whatever trauma or insecurities we may hold around money, you get a combo that can lead to desperate decisions. People who want to take advantage of us know this.

A third thing- we care about our licenses. We may not always have personal or professional morals that align with the law per se, but we don’t want to end up in a situation that would cause us to lose our license and therefore our livelihood.

Finally, while there are many second career therapists, there are also many therapists whose post degree work has only ever been in mental health. Even those who come to therapy from another professional background were often in adjacent fields before. In short, we can be naive sometimes. A lot of us have never truly worked in a traditionally corporate environment. That impacts the way we approach work, treat our colleagues, and expect to be treated. The idea of working in a highly competitive work environment is pretty foreign to a lot of therapists. These experiences can all contribute to that naiveté. And it’s often hard for us to recognize in ourselves, because in many other ways, we’re not naive at all.

Most of my friends in other industries have no idea what it’s like to show up to work and de-escalate a threatening individual in a meth-induced psychosis. They don’t hold thousands of stories of pain and trauma like I do. They may be able to zone out in meetings. I can’t, because my meetings are therapy sessions. My corporate friends simply don’t have to think about what I think about at work every day. And yet, I’ve had to learn over the years that I can still be unprepared for corporate encounters- whether it’s surviving in a tech company or discerning offers and partnerships that would be exploitative. My work environments have just always been so different.

Alllll of these factors in all their variations can result in a sort of desperate hope that there’s a way for us to make more than $50k with a master’s degree out there, below average awareness about financial traps, an industry culture that generally emphasizes collaboration and strengths-based language rather than an impersonal or even cutthroat approach, and the default behavior of giving people genuine attention.

I absolutely did not know a lot of these things when I was an early career therapist or when I first started my private practice years later. And now, the more I supervise, the more I see early career therapists who are excellent and intelligent fall for or almost fall for every one of these. It’s not about intelligence. It’s just about realizing the particular vulnerabilities we may hold as therapists, and what that means to those who want to make money in shady ways.

1. An issue with your license has nothing to do with law enforcement.

Law enforcement will never contact you about a professional issue like that. Our licenses are governed by regulatory boards. Ethical violations and grievances are also dealt with by licensing boards. Even if you were to get a malpractice suit, it would be served through normal channels. Nobody is asking the county sheriff to serve you or personally call you. Always a scam.

2. Real subpoenas can be easily traced back to their source, and reputable attorneys should not drop a subpoena on a therapist they’ve never spoken to.

If you get a subpoena that is a surprise or downright confusing, slow down. And if you get some kind of scary letter that you’ve missed a court date, again without any previous knowledge of what they’re talking about, stop. This is almost always also a scam, and they’re trying to scare you into making a bad decision out of a sense of urgency and fear.

I honestly did think that it was common for attorneys to serve a therapist with no prior notice. What I’ve learned from attorneys over the years is that this approach is usually just sloppy work. If an attorney has a case, and you’d be helpful for that case, they should want to build a collegial relationship with you. They are perfectly capable of calling, emailing, or setting up a meeting to discuss the case. The client often will discuss it with you too so it’s not a huge surprise. Plus, you’ll want to have a contract for legal and professional services to review with clients and attorneys prior to moving forward with anything. All that to say- an odd subpoena should be inspected first.

3. Don’t use a new client’s systems for anything, especially telehealth or payment.

This is a really common scam right now. “New clients” contact you, wanting to schedule. It often seems pretty normal at first. But then they either want to have a consult using their personal zoom link or something similar, or they want to pre-pay for sessions.

Both of these are huge red flags. Regarding the telehealth platform- that’s just always a no. Best case scenario, it’s not HIPAA compliant. Worst case scenario, they’re installing malware on your device.

And with payment… basically what happens is that they pre-pay, and then they cancel, demand a refund, the check bounces… something like that. Except this happens so fast that you’ve returned their money before they ever actually paid it to you. And now you’re out that money. Real clients don’t ask to pre-pay regular therapy sessions. Why would they?

You are the provider. Real clients expect you to give them the systems they need to work with you.

4. There are absolutely some private practice and business coaches for therapists who are excellent. There are also many who basically function like MLMs and pyramid schemes.

I’ve almost gotten pulled into this trap several times, and did get pulled in once. My practice was less than six months old when the pandemic hit. I was desperate to figure out how to thrive in an environment that was so precarious and constantly changing. And everyone was launching online businesses at that time, so it constantly infiltrated my algorithm. I spent over $2000 I absolutely did not have to work with a coach, and I didn’t even finish the program. There was maybe an hour’s worth of content I didn’t already know, even being that new to private practice. And there was basically no live time with the coach herself.

My personal red flags for business coaches:

• They sell a huge signature program that is financially inaccessible, but their messaging makes you feel like you can’t NOT afford it. Nope. To me, that sounds like “I don’t have much to offer, so I’m going to manipulate you into giving me the money and then you’re SOL.”

• If you start asking more in-depth questions about their program, they gaslight you. They tell you that you’re just not dedicated enough to move forward, you’re not embracing abundance- shit like that. Not ok.

• They make big promises about how your income will grow without ever looking at your actual business model. Income for therapists is highly variable and highly individualized. This big promises are just bluffing.

• Speaking of that, I get so annoyed with the “$10k months” promise I see from coaches all the time. This sounds good to most therapists, who quickly calculate it in their head and think they’ll make $120k a year (and when they’re probably making half that or less at an agency, yeah that sounds amazing). They’re actually promising $10k gross revenue, but leaving it just vague enough for inexperienced practice owners to fill in the blanks incorrectly. Many therapists take home around 50% of their gross income. So the coach is basically promising you a $60k salary. Woo hoo?

• Their program focuses on helping you grow a coaching business to help other therapists also become coaches. This is the classic MLM move. Where’s the end of the line? Who actually has a thriving coaching business because of a program like this where they’re coaching clients with needs other than wanting to be a new coach? Nope nope nope.

A solid business coach will be more transparent, not make promises they can’t keep, be realistic with you if you’re not a good fit for their services, and will tailor your work together to what you actually need.

5. Random media outlets that offer you a big interview, conference attendance, even a TV spot, without you actually trying to get any of those things.

Look. I believe that your work is incredible and you absolutely do deserve to be interviewed. But this stuff is never legit. Usually, you start talking to them, they continue to pump you up, and by the time they share the fine print of how much it will cost you to do this, you’ve gotten the opportunity all built up in your head and it can feel so hard to realize what’s happened and let it go. What gets tricky is that these media outlets might technically be real, but they never have any actual credibility that would help your business.

6. Insurance companies will bully you. Don’t bow down to them.

While not technically a scam, this is absolutely shady behavior. Insurance companies love to send letters to therapists stating that you’re billing 90837 more than your peers, and you should probably stop that because you’re over-billing. There are many problems with this.

The insurance company doesn’t say who they’re comparing you to. Think about integrated care services that bill 90832 or 90834 most of the time. School based therapists often bill for shorter sessions. Therapists who work with kids in general may bill for shorter sessions. They’re all psychotherapy codes, but they’re not all the same service. Beyond that, the insurance company is not stating that your services are not, in fact, clinically appropriate for 90837. They’re just trying to bully you into either doing shorter sessions or doing the extra time for free. Justify your work in your documentation and mentally tell them to fuck off.

In general, if it sounds too good to be true, it is.

If it immediately causes you to panic, regulate first and then ask why.

Cheers to all of us being more discerning and keeping as much of our money as possible.

As always, thanks for reading.

xoxo

Laura

Now, I’m sure those therapists do work with life transitions, perhaps very effectively. Every therapist I’ve ever met works with clients who are dealing with difficult and impactful life transitions. That’s exactly the problem.

Life transitions is one of the most ineffective phrases you can take up space with on a marketing page. It’s way too vague. And on top of that, nobody is searching “therapist for life transitions.” That’s not how people describe their presenting concerns. People search for a therapist to help them with what they’re actually going through.

The good news is that it’s pretty easy to go from “life transitions” to a valid and relatable niche. These are the 3 pieces I recommend brainstorming around to rework your niche.

1. What’s the actual life event?

There are countless different life transitions that humans go through: childhood developmental milestones, changing schools, moving, starting or ending college, entering the workforce, changing careers, new relationships, getting married, break-ups and divorces, birth or adoption of children, caregiving for loved ones, loss of a loved one, pet loss, estrangement, faith deconstruction, loss of community, financial stressors, accidents, gender affirming care, exploration around identity, medical diagnoses… that’s just what I could think of in the last 30 seconds.

My guess is that you’re not equally good at working with every single one of these events. And you don’t need to be! Focus on the actual life transitions that you enjoy working with and are competent in. Naming a few of those instead of the general “life transitions” terms is already more effective.

2. Who goes through this life event?

Once you’ve identified a few events that you work with, consider who often goes through those life events. Children at different life stages, new grads (at any level), postpartum moms, people with a newly diagnosed medical condition, widowed partners, empty nesters, newly divorced people, single parents, military families who go through transitions every few years, immigrant families, caregivers, job seekers… again, there are countless options here.

Some events can happen to anyone, while others are often experienced by certain populations. You can tailor this But now you have two parts to your niche:

“Adults going through a divorce and adjusting to single parenting”

“Sandwich generation adults who are caregiving for both parents and children”

“New grads entering the workforce”

“Women experiencing perimenopause”

“People who lost their spouse before age 60”

“Young adults with a chronic illness”

Even if lots of different populations may experience the life events you enjoy working with, that doesn’t mean you have to cover every possibility in your marketing. In my experience, plenty of clients outside of my niche or adjacent to my niche have contacted me over the years. If someone is interested in working with you, they’ll probably contact you. You both can determine goodness of fit in a consultation or first appointment. But if that (generally false) anxiety around exclusivity leaves you with a niche that is way too broad, clients won’t even find you.

3. What symptoms are these people experiencing because of this life transition?

What kinds of symptoms, diagnoses, or concerns are happening for people in your chosen population and life transition?

Maybe your ideal client is experiencing panic attacks because of the new situation they’re faced with. Maybe they’re grieving and in a depressive state. Maybe they meet criteria for PTSD because of the accident. Maybe they’re overwhelmed and burned out, and that is prompting them to consider a new career, but the thought of financial insecurity is keeping them stuck. You may name mental health symptoms and diagnoses, or you may speak to other aspects of a person’s experience that are not necessarily clinical language.

Put it all together

Put all three of these factors together, and now you’ve got a working niche. Instead of life transitions, you can speak to divorced moms who finally got into the groove of single parenting, only to be hit with perimenopause. You work with men who lost their spouses at a young age, and are experiencing prolonged bereavement and depression. You can support military spouses who are so used to uncertainty, they’re not sure how to help their bodies feel safe anymore. You’re the perfect therapist for gender expansive adults who are navigating their identity after faith deconstruction, while also grieving the loss of their former community.

If you use this 3 step method, I’d love to hear how it goes for you! Wishing you a full calendar of clients who are just the right fit for you. ✨

As always, thanks for reading.

Laura

If you love my writing, tip with Buy Me a Coffee! Proceeds absolutely go to coffee, my #1 coworker.

Hi! I’m hoping to leave my agency job soon and want to start a solo private practice. I want to bill insurance, but individual credentialing and billing feels overwhelming. So I’m thinking about joining a platform like Alma, Headway, or Rula. What platforms do you all recommend?

Ah, the comments:

Hopeful Heather: I just joined Alma! Their rates are so much better than what I was making at a group practice. I want to double my income this year!

Eager Evan: I’m on Headway, Rule, Grow, Alma, Talkspace, and BetterHelp! I can take every insurance plan that has ever existed. For some reason I can’t identify, I’m overwhelmed.

Judgy Jane: All platforms are evil and you’re unethical for even considering working for one.

Clueless Cathy: What’s a platform?

Influencer Isabella: Here’s my referral link! Rula is incredible and I can’t imagine working anywhere else! Truly the best and I’m not just saying that because of my contract!

AI bot that somehow got in: This is the differentiator to consider. All VC-backed platforms offer different benefits.

Discouraged Dan: I’ve been on 4 different platforms for 6 months and have gotten 2 referrals. Don’t even bother with a private practice, it’s impossible.

Sound familiar?

This discourse alone can overwhelm therapists attempting to start a private practice and take insurance, which often tends to result in one of two ways: joining a platform without much discernment hoping for the best, or throwing up your hands and thinking you can’t do this.

It’s a complex process. And yes, you can do this.

No judgment from me if you join a platform. I’m on multiple platforms right now. But you do need to think critically about what you’re joining, and you need to set up your practice to retain as much autonomy as possible from any services or billing partners.

Why?

1. Because platforms do not have the best interests of you or your clients at heart. They literally can’t. When push comes to shove, they literally, legally, have to choose what is best for their shareholders. And they will do it at your expense.

2. The worst case scenario. If you’re reliant on a platform for all the essential functions of your practice - EHR, telehealth, credentialing, billing, client referrals, communication channel with clients - and the platform shuts down tomorrow…. now what? You functionally shut down with the platform. There’s no room to pivot. You were dependent on them and now you have no income and your clients have no care.

3. Because it’s your practice. Period. Starting a private practice isn’t a fun little hobby. It’s a business. Take ownership of it from Day 1, even if you plan to keep it very small. If you treat your practice like a hobby, it will become a very expensive one real quick.

First- what am I talking about when I say “platform?”

In this context, I’m talking about a venture capital backed, tech-forward company designed to offer supplementary services to therapists in private practice. All these bullet points are kinda saying the same thing, but it might be helpful to look at from different angles if you’re new to this.

• They do not hire you. If you meet criteria to join, you can join.

• You become a 1099 Independent Contractor of the company when you join. Platforms have W2 roles in their corporate offices. But therapists use these adjacent services in their businesses, and payments are reimbursements from insurance companies and any other session fees that the therapist runs through the platform. You can be a contractor with multiple platforms, and work with other billing partners or practices as well.

• Related to hiring, these companies do not offer therapeutic services directly. Most of them have some kind of directory that potential clients can search to find a therapist. And vice versa, when you join as a therapist, there is no guarantee of a certain number of referrals sent your way. You don’t work for them and you don’t receive a salary from them.

• So related to the 3 things above, platforms are adjacent but separate from mental health tech companies that directly hire therapists, such as Headspace and Meru Health. These companies often still hire therapists on a 1099 basis (and yeah, the ethics of that are shady), but they have much more ownership over the therapists’ work.

• These companies are also distinct from companies that offer EHR software, such as Simple Practice, Therapy Notes, Jane App, Sessions, and TheraNest. Most EHR companies just offer that: web-based applications or software to house medical records, collect payments, offer telehealth in many cases, and serve as a clearinghouse for insurance billing. EHR companies generally are not involved in credentialing with insurance panels.

• The big name platforms all provide most of the same essential services. They collect the info needing for credentialing applications and manage them for you, which are usually group contracts (you lose your in-network status when you leave). They often provide some kind of basic EHR or provider dashboard. Many have a built-in telehealth option. Some include things like free CE’s and other resources. They handle insurance billing and payments. Many of them include a client-facing therapist directory for potential referrals. Different bells and whistles are on different platforms, but this is what they all boil down to.

So now that we’ve established that, this is what I would do (and have done) to maintain as much autonomy, flexibility, and stability as possible while working with platforms. This is my own opinion, so strongly worded or not, of course you always should consider what is the best decision for your practice.

1. Get your own professional email and business phone number.

Don’t rely on a platform’s messaging features as your only form of communication with clients. If something shuts down, isn’t working, you lose power, etc. you need to be able to get in touch with clients. And since tech companies are notorious for locking therapists out on short notice, it’s an easy way to help ensure continuity of care for your clients in a bad situation.

2. Consider having your own telehealth option.

Most platforms and EHRs offer built-in telehealth now. They can be handy, for sure. But it’s way less handy when you’re using multiple platforms, have non-clinical meetings, provide supervision, or need video calls for anything other than client sessions. I’m all about consolidating and streamlining, and multiple telehealth setups that I’d have to switch between every day is just tedious and annoying, in my opinion. I pay for the HIPAA compliant version of Zoom. Yeah, it’s another business cost. But it’s so much easier

3. Review the language you use to describe your practice.

If your website or a therapy directory page says that you are a “Headway therapist” or “provide therapy through Alma,” you’re giving away your autonomy for no reason. You are a private practitioner. You own your practice, and that is the ultimate entity. You work with platforms for billing support. Adjusting this language is also a simple way to reinforce with clients that they work with you, an individual human being, rather than a big, impersonal company.

4. Don’t let compliance emails intimidate you. But make the effort to understand what they mean.

I’ve gotten plenty of compliance emails from platforms over the years. Insurance companies are tightening their standards. Don’t over-bill 90837. Make sure your treatment plans are compliant and use SMART goals. Evidence-based practices. Watch out for audits.

These emails don’t have to be scary. Getting an email that says “we’re getting too many 90837's” does not mean you need to stop billing it. But if you do immediately, because you’re scared of denials, they retain or grow their profit margin and you make less. Win win for them.

Instead, take the time to read these kinds of announcements thoroughly and understand what they are actually saying. Insurance companies dictate our work too much as it is; don’t let platform bullying make it worse. If you’re not sure how to justify your work or what steps are needed, consultation is always a good place to start.

5. You often don’t have to panel with every insurance plan.

Many platforms don’t actually require you to panel with every plan that they offer. For a solo practitioner, just taking a few plans should easily fill your caseload. Choose the ones that make the most sense for you, such as the plans that pay better or are more common in your area.

6. Don’t give a platform your marketing channels for a tiny reimbursement.

Several platforms offer to “manage” your Psychology Today page or another therapy directory page, and will give you a few hundred bucks for it. Usually, this involves changing the website listed from your own site to your profile on the platform’s directory. I mean, if the clients get to you regardless and you get some money, why not?

Well, this is what’s actually happening. Platforms are already buying up huge amounts of ad space and rigging therapy directories like Psych Today. Every therapist who gives their websites more clicks helps them, not the therapist. When clients find you on your own site, you can much more easily determine how to move forward with them (which leads to point 7 below). If you’re going to take their money, quietly change your website back the next day. I seriously doubt anyone will notice.

7. If you’re on more than one platform, work the system. Bill the highest paying platform for each plan.

If you’re on multiple platforms, chances are you have multiple contracts with several different insurance companies. Make a spreadsheet and track all the rates, so you can easily see who pays the most. And route new clients through accordingly. This is another reason why having your own marketing channels is essential. When clients find you through your own marketing, such as a therapy directory page or your website, you can bill them however you want. When they directly come through a platform, it can be harder to move them off that platform.

8. Be ready to leave at any point. When the tides turn, they will choose their shareholders over you.

Finally, you have to sleep with one eye open. Platforms can be useful. They can make credentialing faster, billing easier, protect against clawbacks, and may very well offer better rates than what you’d be offered on your own.

But only stay with them as long as they are useful for you. Remember, they will always choose their shareholders over you. This is not a partnership. It is two parties tenuously using the other until it is no longer a mutually beneficial relationship. At that point, either you’ll be able to exit quickly (because you’ve done all the other things above!) or you’ll be stuck in an increasingly abusive relationship. Choose wisely.

I hope this was a helpful crash course on both using platforms and ensuring that your practice is still as autonomous as possible! If you want to strategize more depth, I offer professional consultation to other therapists. As always, thanks for reading.

xo

Laura

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Many of you stay in my heart forever, even if we haven’t spoken in years.

Even though I may have to talk about diagnoses, treatment plans, and interventions sometimes, just know that your story is so much more unique, important, and complex than that.

To be a small part of your healing is sacred. To be the recipient of your vulnerability is a great honor. And to witness your creativity and flourishing is a precious gift.

Yes, I totally wish I could see photos of all the people you talk about in therapy. At least describe them like you’re writing a book or something???

Sometimes I know if we’d met under other circumstances, we’d be friends. So even though I’m honored to know you as a client, part of me is sad to not know you as a friend.

None of the stuff I say during a risk assessment or a safety planning discussion is bullshit. The world really does need you, even if that’s hard to see right now.

I deeply believe in your autonomy to make whatever choices you’re going to make. But it’s still hard to watch the process unfold when you’re making choices I know could hurt you, or actively are hurting you.

If you see me glance at the clock during our session, it’s not because I’m bored with you. Knowing the time helps me pace our sessions so that we can cover everything you wanted to discuss, and it also helps me keep my whole day on schedule so that each of my clients get the time they deserve.

No, you don’t sound crazy.

Ending therapy is hard for me too, and sometimes I take it harder than my clients. I want to see you get to that day when you don’t need me anymore, and move forward with me as a hopefully helpful memory. But I know the ambiguous grief of having thousands of former clients out there in the world whom I knew so deeply at one point, and now I’ll never see again.

The longer I do this work, the less I realize I really know. I don’t say this coming from a place of imposter syndrome. It’s just true. For me, that just speaks to the expansiveness of our realities and keeps me curious.

The hourly rate you pay is not what I take home per hour. I know a lot of people are aware of how service based businesses work and aren’t judging it at all. But I still struggle with knowing that some people think I’m just raking in cash at the expense of hurting people, when that’s not true at all.

Good therapists want feedback. I went a totally weird direction? Tell me. I used an intervention that backfired? Tell me. You felt unheard or misunderstood? Tell me. Feeling safe enough to share stuff like that with your therapist is actually great, and I will never judge you for that. I’m just a person at the end of the day, and I make mistakes. Whatever it is, I want to be able to work through it with you.

Sometimes I feel lonely in sessions. These relationships take up so much of my day, my life. But they’re ultimately one-sided. Sometimes I find relief in that, and some days I wish I could be seen too.

Not knowing how many of my clients are still alive haunts me on a regular basis.

I get self-conscious in the therapy room too sometimes.

Some days I know I’m not giving you my best work, because I didn’t sleep well, or I’m not feeling good, or I’m going through stuff in my personal life. I know it’s just part of being human, but I still feel so guilty about it. I wish I could give every single client my A game every single session. I know I can’t and that sucks. But I also recognize that this expectation is largely coming from me, not you. We both deserve self-compassion.

You do the healing, not me. I’m a midwife, not a surgeon. Yes, that’s a reminder that you’re accountable for your healing. But it’s also a reminder that you deserve to take credit for every ounce of progress you make.

And finally…

Girl, dump him.

As always, thanks for reading.

Laura

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This field has given me plenty of opportunities to build my resilience. I’ve been threatened and screamed at. I’ve worked for $22 an hour with a master’s degree. I’ve done swing shift and nights in psych hospitals and EDs. I’ve used my personal car to drive all over the Denver metro, to meet with clients in the worst parts of the city, armed with my water bottle and a notebook. I’ve worked with many individuals with those diagnoses that are severe, rare, and stigmatized. At one point, I was barely making $55k with an independent license and EMDR training, wondering how I would ever be financially stable.

In my earlier roles, I was often focused on the issues in my own workplace. The city or state’s systems. My part of the industry. But I still thought that out there, somewhere, was a golden job. A full time clinical trainer role. A caring group practice with regular raises and a cash-pay caseload ready to go. Solo practice where I could be my own boss and take vacations whenever I wanted. I thought my jobs had been awful, but surely that wasn’t everywhere. I’d find it one day.

And then I started a private practice, and it wasn’t so easy to thrive. I figured it was just a learning curve. Then the pandemic hit and chaos ensued. I couldn’t pay my full rent my entire first year in private practice, and was only able to keep going because of my partner’s support. I figured out a few things, and got a lot savvier about the insurance system and entrepreneurship. I made my practice work for as long as I could, and then worked for multiple mental health tech companies during the pandemic VC boom.

My second gig in tech was a salaried W2 position at Ginger. Here it is. The golden job. And it was, at first. So golden. Good money, great benefits, unlimited PTO (?!), *swag* sent to me for onboarding, nice clients, friendly manager, a new Macbook Pro for my work laptop instead of whatever mid 2000s desktop is available in the agency office. Shortly after I started, we were informed of the merger with Headspace. I wasn’t afraid of that at all. I didn’t know I should be. I’d only worked in medical systems and non-profits. Frequent layoffs, corporate lingo, and recklessly fast change weren’t exactly the vibe.

Headspace Health taught me about golden handcuffs. The salary I couldn’t find anywhere locally came with “unlimited” PTO, but I had a relentless productivity quota to meet regardless of days off. Within a few months of the merger, they added more limits to the number of sessions, metrics, and modalities used. Next came the policies that showed complete disregard and disrespect for the entire clinical team, but were presented as if they supporting us to provide better care.

I left within a year. If I had stayed, I might have gotten laid off with 180+ other therapists, who weren’t even given a chance to notify their clients. They provided clients with information that was completely untrue and insinuated that the therapists had walked out without providing notice. It backfired on them later when an article about it went viral.

Meanwhile, I was so completely crispy fried burnt out that I quit therapy entirely for a full year. I walked away with no plan, got pregnant, built and crashed a virtual assist business, had my son, and went on maternity leave all in the next 12 months. The VA business’s crash gave me the painful clarity I needed to realize that I was ready to come back to clinical work. I tied up loose ends, shut that business down, and reopened my private practice.

That’s where I’ve been for the last 3 years. And although my days can feel very micro-oriented, being in this space has generally widened my view. Now I see the whole mental health field, the insurance industry, political impacts on healthcare, access to care issues, and wide scale trends in mental health. The biggest takeaway? There sure as hell is no golden job in this field.

Private practice cannot be a thriving job in mental health if that private practice is insurance-based. I truly don’t believe it’s possible. To make a $100k salary as a solo practitioner, your business income would need to be closer to $200k a year. It’s literally not possible for one person seeing hourly clients.

You have to go fully private pay and/or add other streams of income. You can’t just do your highly educated job full-time and survive. You can make a great income if you have a higher cash rate. But in most cases, that still means seeing a lot of clients. There’s no work-life balance and tons of vicarious trauma, now being experienced largely in isolation. You can become a clinical supervisor, or create a course, or write a book, or try to make it on TikTok because why not. But they’re all things that take up a ton of time and energy, so now you really have no work-life balance and are burned out once again. I’m constantly trying to evolve and get to the point at which I can feel secure in my income. But the process is exhausting.

And what about the way therapy has skyrocketed into the mainstream? Sure, we’re talking about mental health more than ever. But that doesn’t mean we’re actually improving it. We’re only even really talking about it because investors thought it would be an easy win during the pandemic. Those same investors have given us no additional resources or actual support as a profession. All they do is commodify therapy and exploit therapists to get to their massive profit margins.

VC backed companies are getting bolder with their rate cuts and obvious measures to limit our autonomy. Insurance companies are tightening their grip with things like buying out CAQH. Google and therapy directories are flooded with million dollar ads and profiles that funnel clients toward whatever platform bought them. Some new bullshit surfaces every day.

I was in a meeting the other day and was told “payors are trying to manage their costs any way possible.” Yes, and they’re choosing to manage their costs by exploiting and stealing from the individual providers - the people at the bottom of their barrel. Approximately 430,000 therapists are in network with United. If they gave every single one an increase in reimbursement rates that would equal a $10k raise, that’s $4.3 billion. Which is a lot, yes. But still $8.9 billion less than their annual profits. A whole lot of investors and higher-ups at insurance companies certainly aren’t on the receiving end of “managing costs,” and all major insurance companies are making sizable annual profits. Here are the 2025 year-end profits for the top 5 biggest insurance companies:

• UnitedHealth Group: $12.1 billion

• Cigna Group: $6.0 billion

• Elevance Health: $5.7 billion

• CVS Health (Aetna): $1.8 billion

• Humana: $1.2 billion

Managing costs indeed.

I don’t feel like even writing a paragraph about AI and mental health. Find one of the millions out there. I’m not afraid of Chat GPT taking my job. I’m annoyed at the attention it’s getting in the mental health space when it solves very few of our core issues and is actively making my supervisees worse at theory and documentation. But more than that, I’m afraid of the ways that AI will gradually water down our intelligence, social connections, emotional capacity, and societal stability. All of those things are necessary for mental health. If you think there’s a therapist shortage now, just wait.

Take a deep breath, because I’m just now getting to all the problems with therapy that have existed long before the last decade.

Our current understanding of psychology and therapy is largely based in the opinions of old white men who studied young white men or animals and then extrapolated that to the whole world while simultaneously ignoring and erasing non-Western and Indigenous wisdom. I think most of us know that by now, right?

All the diagnoses, all the medical models, all the individualization of issues that can only be solved through collective healing, all the parameters… How often is all of that truly healing and helpful?

I find myself stuck between this increasingly standardized and automated world of clinical therapy, and the art and mystery of actual bio-psycho-social-spiritual healing.

I know how to play the game. I know how to translate I’m actually doing in the room with my clients to the clinical language and reductive goals required by the insurance circus. I know the diagnoses and the assessments. I can do all of those things to keep my practice functioning while still being an authentic, relational therapist. But the tension is growing. It’s becoming an ethical dilemma, an identity dilemma, that I can’t take much longer.

Our understanding of psychology and spirituality has been shaped largely by power and control, not truth. So much of our wisdom is lost. So much of our truth has been covered up or ignored. At what point do we stop telling ourselves we truly know how to help?

Therapy is too much of an art for the medical people, and considers itself too much of a science for the spiritual healers, shamans, or clergy. Mental health doesn’t quite know where to fit. I think that’s probably because it’s a modern answer to an ancient problem. Therapy has only existed for a short blip of time. But we refuse to look to the other forms of knowledge who could help us. And by “we” I mean our licensing boards, our professional associations, and the insurance companies who decide which professions they’ll pay.

I still believe in therapy. I’ve worked with thousands of clients. I’ve experienced the progress, the lightbulb moments, the healing, the changed lives. I’ve benefitted from therapy personally. I know that when the conditions are right, it really works.

But I think therapy needs address its identity crisis and take its place next to all of the other healing arts and modalities. Therapy will never replace systemic change or healthy relationships or reasons to live. Therapy is personal training, not the marathon itself. Therapy can’t be the answer to every mental or emotional problem. And while I think a lot of therapists know that, the field is stuck grappling with increasing pressure to fix everything anyway.

We’ve brought instant gratification culture to therapy, too. But we cannot outsource our humanity to therapists and expect that hour a week to do what we’re unwilling to do the other 167 hours.

So… yeah. I believe that therapy can be salvaged. But I also believe it needs to be rebuilt, not just touched up. Not through a marketing campaign, another “innovative” startup, or AI. But slowly and steadily - through asking the hard questions, sitting with uncertainty, decolonizing everything from the theories to the licensing fees, supporting the infrastructure that can allow both therapists and clients to thrive, and redefining our own professional purposes and identities. I’m ok if that all takes a while… it’s a tall order. But the alternative is to watch insurance companies run the whole field into the ground, until there is truly nothing left to salvage.

As always, thanks for reading.

xo

Laura

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I sang in the show choir, did all the band stuff, and was playing classical piano competitively. And all that work paid off. I went to college with the help of a piano scholarship, and started my college career as a music major. I was burned out from band by that point, and chose to join the choirs instead.

Even though I ended up switching to psychology as a sophomore, I stayed in both the piano studio and various choirs throughout my undergrad years. I sang in Italy with my university’s top chamber ensemble. For the first 22 years of my life, music was essential.

And then, without even realizing it, I took a break from organized music for years. I got so involved in grad school and then my (very intense) career as a therapist that I just didn’t think about the fact that community musical organizations exist. I finally joined a community choir here in the Denver Metro (shout out to the Arvada Chorale) in 2018, and over the years, this group has become one of my core communities. I love those people so much, and I love singing with them. So at this point in my life, my main musical identity is as a singer.

I’m telling you all of this because even though I have never been a professional musician, I do have a genuine musical resume.

But you know what the bane of my existence is?

Karaoke.

Yep.

You’d think that would be easy, right? I’m an actual singer.

It is fucking not. There is a whole mental game here. I can’t go up there and sing my drunk, tone deaf heart out and get the crowd going through sheer lovable obliviousness. I’m not tone deaf and I’m incredibly self conscious. Which means my only other option is to be good.

Again, should be easy. But there’s something so different about karaoke than actually getting up on stage and performing a solo in front of an audience. The typically bad sound system? Getting in my head about the pace of the lyrics vs. what I’m doing? Is it simply that my voice is much more Broadway/classical than pop? Do I just… sound bad? Like wtf that is not normal.

I DON’T KNOW.

But honestly… I do know. The actual reason why it stresses me out is because I expect to be good. I’m comfortable in musical spaces, and I have grown to expect that I will generally be accepted and respected in them. The idea of being bad at something musical, of being a beginner again, completely gets in my head. It’s why I’ve never learned to play the guitar, even though I’ve always wanted to.

This fear extends to a lot of areas in my life. I have always been a perfectionist to an extent. I’m an eldest daughter raised in a high control religion, top of my class in all 3 degrees, an Enneagram 3, and am now a highly attuned, relational, complex trauma therapist. So like… no shit I hate being bad at stuff. I learned early on that being bad at stuff had consequences.

But since then, I’ve learned that’s not true. I’m learning how to let others into vulnerable parts that feel ashamed or embarrassed. I’ve experienced the healing of some of those parts, and have gotten so much better at showing myself compassion. I know that being bad at stuff is one of the biggest ways I can grow. I have to learn to work through the anxiety and perfectionism, embrace not being good at something at first (or possibly ever), accept myself as inherently worthy aside from my accomplishments, and just have fun doing something without turning it into a thing.

And so, my new personal growth assignment: go to karaoke. Take all the opportunities. Keep practicing. Let myself be bad on stage without crumpling. Go with friends. Go by myself. Enjoy a new style of singing. I have to be a beginner and get comfy with that.

I’ll let you know how it’s going in 6 months or so. I don’t know if my goal is to actually get good at it or just be able to get up there and enjoy it. Maybe a little of both. But I know that I have to start somewhere.

Maybe someday, I’ll even start guitar lessons.

Do you have a karaoke? I’d love to hear about it.

As always, thanks for reading.

Laura

As a result, my first year was kind of a mess. I did some things right. I was able to fill my caseload in about 6 weeks. I was definitely not sitting around waiting for clients that first year. And not all of the messes were my fault. I have learned to give myself compassion for how I navigated the pandemic, because literally none of us knew how to manage that at first. But I also did a bunch of stuff that just didn’t work for me. I took a bunch of insurances, I saw clients in multiple offices, I worked with clients outside of my preferred hours, I took on clients who weren’t that great of a fit for me, I attempted marketing strategies that made no sense for what I was doing, I spent too much money, and I tried to DIY things that really shouldn’t be DIY’d. I made $60k in my first 12 months. Gross revenue. And had an $8,000 tax bill. So yeah, not great.

I did so much work that first year without really understanding what my business actually needed to thrive. That cost me a lot of time, money, and energy. By early 2021, I was exhausted and very much in a scarcity mindset. I was well aware that my practice was not sustainable as is, but also had no idea how to change it. I was stuck in what I was “supposed” to do. I ended up taking a 1099 part-time job, and then eventually effectively closed down my whole practice to take a full-time therapy job in the booming mental health tech sector. When that proved to be a whole other kind of burnout, I took an entire year off from therapy, and then restarted my practice from a much more intentional place.

Now, many of my practice policies are not because some business coach recommended it. It’s because I’ve found what works for me. And I hope it goes without saying that what I’ve done might not be what works for you and your practice. But I hope I can help you give yourself permission to consider some of these areas, and recognize what actually makes sense for you.

My cancellation policy fits my life.

Area to consider for your practice: cancellation policies and professional boundaries

I have a really flexible cancellation policy. Why? Pretty simple. I need flexibility too. I’m a toddler mom. My darling, tiny germ factory brings some new daycare virus home at least once a month. And since we don’t really have back-up childcare options, it often means my husband or I has to clear our calendar at the last minute to take care of a sick baby. Sometimes I’m the one sick. Sometimes life just happens. And I recognize that for my clients too.

I understand that I could charge late cancellation fees more often if I had a stricter policy. I’m okay with that. I know how much many of my clients are investing in therapy, and I don’t feel the need to charge full fees for the sessions they miss. I ask to be notified of a cancellation by the morning of the session. I consider it late if the clients cancels within that day or no-shows. I give everyone a first time freebie, and after that I charge a flat $50 fee. It’s straightforward, doesn’t overly punish clients, and I can enforce it without feeling guilty (which yes, is likely more about my relationship with money than it is about charging the client. I’m working on it ok!). And when I’ve needed to cancel sessions unexpectedly, my clients are generally really understanding. I’m also very aware that at some point, it might make sense to change this policy.

Ultimately, your cancellation policy can be as strict or as lax as you want. There’s no one way to do it “right.” What matters is that you can confidently enforce the policy without violating your boundaries, ethics, or values.

I’m always fine tuning my clinical specialty.

Area to consider in your practice: specialties and clinical niches

I personally think it’s beneficial to have a clinical specialty. You don’t have to, and there are certainly generalists who have sustainable and rewarding careers in private practice.

But for me, having a specialty serves my practice in several ways. It gives me foundational parameters for everything that I invest in as a therapist and private practice owner. By focusing my continuing education and most of my clinical work on my specialty, I am always building up legitimate and advanced expertise in these areas. It makes it easier for me to talk about what I do when I’m marketing. It makes me more confident in talking to potential clients. The clinical work refuels me differently. I can stand out more in directories and platforms, because I offer something more specific that some clients are directly searching for.

As someone who has many different interests and passions, it would be really easy for me to go all over the place in terms of both clinical work and training. That approach might totally work for some people. But it overwhelms me and makes me feel less effective. Having a specialty, and consistently reviewing and fine tuning it, really helps me.

I don’t take every insurance possible.

Areas to consider in your practice: insurance vs. private pay, payment methods, credentialing

Whether or not to take insurance is a major point of discussion for most new practice owners. I do take insurance, but I also totally understand why many therapists don’t.

But one thing I wouldn’t recommend is getting credentialed with every insurance plan you can possibly be eligible for. If it’s just you, you only need enough clients to fill your caseload. That’s it. Sure, you’ll have clients come and go. You’ll need to fill your caseload many times over the years. But still… it’s just you. You don’t need thousands of clients.

Taking a few insurance plans can absolutely give you the referral stream you need. You don’t need 27 different plans, panels, and platforms to make your practice work. When you do take numerous different insurances, it just makes billing more complicated and your revenue harder to predict.

My advice would be, if you want to take insurance, to accept a few plans that offer above-average reimbursement rates, are relatively easy to work with (whether you are independently using a provider portal or work with a biller/platform), and are reasonably common in your state(s) of licensure. That is plenty for most solo and small practices.

I don’t post on social media constantly.

Areas to consider in your practice: social media, content creation, marketing

I don’t even post on social media often. I’m pretty sure the last time I posted on my professional instagram was to announce that my practice was reopening- 3 years ago. I do post on LinkedIn somewhat regularly, but I don’t have any particular schedule. That’s about it.

I have no issues with therapists utilizing social media for marketing and/or content creation. It’s the world we live in, and I think it’s better for people to receive mental health content from professionals who actually know what they’re talking about instead of a random wellness influencer who looked up “trauma healing” on google one time.

Social media may be a helpful and even necessary tool for your practice depending on your location, ideal population, if your practice is cash pay only, and if you’re offering other services outside of therapy through your practice. And if you just enjoy doing it, go for it! Some therapists are making a significant amount of money from content creation, and that’s fantastic.

I’m really just saying this to reassure therapists who are reluctant to engage in social media professionally but feel like they have to do it to be successful that no, you don’t have to do it. Especially if your blank social media accounts are becoming a barrier to you launching your practice. You can absolutely fill your caseload without it if it’s not something you’re into, and you can always start making content later if you change your mind.

I’ve learned to be flexible.

Areas to consider in your practice: professional boundaries, work/life balance

Change is inevitable in life and in business. The more rigid I was with my practice, the more I resented it. There is a certain amount of rigidity in being a therapist in general. We can’t just decide to skip a meeting at the last minute, or bump something to the next day. Our tasks and meetings are not just tasks and meetings. They are therapy sessions with human beings who are expecting us to show up for them at a vulnerable time in their lives. I usually describe my schedule as “flexible… in advance.”

Since that rigidity is already baked in, I think it’s important to be pretty flexible in basically every other part of your practice. This field changes quickly. Business practices, economics, politics, and trends change quickly. We have to learn to adapt with it all. This might mean changing platforms or software overnight because of a major issue, changing your schedule, taking a mix of payer sources, learning new skills, increasing and decreasing availability, taking on a new population of clients, hiring another therapist, etc. Being flexible can be the difference between your practice surviving a hard time and closing its doors.

I know there are wildly different offers at different companies to do the exact same job. So I choose wisely.

Areas to consider in your practice: professional partnerships, billing, W2 vs. 1099 status

In mental health, direct care jobs all have similar foundations. Generally, if you’re comparing jobs in the same level of care, you’re basically doing the same clinical work at all of them. Sure, there are lots of nuances depending on specialties and populations served at various organizations. But when it comes to basic job functions, an outpatient therapist is an outpatient therapist.

Why is this relevant for private practice owners? Because many therapists don’t have a full caseload of exclusively cash pay clients, especially when they’re first starting out. If you do, I love that for you and you can probably skip this section! But for those who do take insurance or are considering working part-time at a group practice or a similar organization while building your practice, keep reading.

You could see Client A at a group practice, at your own practice billing with an independent insurance contract, or at your own practice billing through a large platform’s contract. It’s the same client. The same work. Likely 3 different rates. So compare them! You don’t have to be tied down to the first opportunity you hear about. You might be surprised at how wide the range of rates can be.

I’m not saying that you should obtain a client through Place 1 and then immediately transfer them to Place 2 for a better rate. That’s probably client poaching, and it’s not cool behavior. Key word here is immediately. If you’ve been working with your clients at one place for a while, and at some point decide to go off on your own or switch platforms or whatever, there is nothing stopping your clients from coming with you. I have very strong opinions about organizations who try to enforce non-competes on therapists, as that violates their clients’ right to self-determination.

The point here is that sometimes it literally pays to shop around before making a commitment to any one system, practice, or billing partner. I’m always aware of new companies, opportunities, and trends in the industry to ensure that I’m taking advantage of the best opportunities possible. And honestly, this also helps me see the writing on the wall when things aren’t going well at a particular company or practice, and get out of there before it has a major impact on me.

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I don’t force everyone into a standing appointment slot.

Area to consider in your practice: scheduling policies

So many therapists think their full schedule has to include X amount of sessions each week, with all of their clients booked into standing appointments. And if/when that doesn’t happen, anxiety immediately goes up. When the therapist needs to make an appointment for themselves or take a day off or whatever, it’s instantly stressful. I don’t know who is teaching new therapists that clients have to book standing appointments. They don’t.

I mean, obviously you can structure your schedule around standing appointments and that’s totally fine. But this is another one of those “in case you thought it had to be this way, it doesn’t” statements. If you’re struggling to make the puzzle work every single week and it’s causing you a ton of stress, remember that you can book some or all of your sessions week to week. It’s not illegal. I’ve ended up with a hybrid approach. Some of my clients have standing appointments and they book out several weeks in advance. Others have flexible or changing schedules, and we book week to week. No big deal.

I outsource what I’m not good at or don’t like.

Areas to consider in your practice: systems, professional services

I’ve figured out what I can DIY and what I just can’t, and I outsource accordingly. For example, I used to do my own bookkeeping and taxes and that went horribly. So now I have full-service accounting. I outsource the vast majority of my billing so that I don’t have to spend several unpaid hours on the phone with insurance companies every week. But I’m totally fine with building and updating my own website.

It’s all about where you skills lie, what you enjoy doing, and if the time you’d take to do a particular task is worth it. I literally think about my hourly rate to figure this out. Let’s take billing for example: I would likely spend 2-3 hours per week on billing tasks, as a light estimate. If I’m dealing with denials or appeals or something, it might be a lot more. My cash hourly rate is $150. Essentially, I’d be paying myself 8-12 hours to do billing on an average month - anywhere from $1200 to $1800. What I invest in having billing partnerships is a lot less than that. It’s worth it to outsource in that case.

Main takeaway: make your practice work for your life, not the other way around.

I know there are a lot of things we can’t control that impact the mental health field and therefore our private practices. Considering all these factors and making adjustments isn’t a magic wand to give you the business of your dreams. But doing all of this can help you recognize your top priorities in your practice, live out your professional values, and gradually build a business that is sustainable. That’s the goal!

These little quirks help me focus and stay engaged in my sessions. In a perfect world, I would always be fully rested, perfectly calm, and ready to give 100% to every single client.

But unfortunately, I happen to be a human. I’m a sleep deprived toddler mom. The world is on fire. I have my own anxiety. Every session involves clearing out my own brain and life, and focusing in on my client. As long as I am capable of doing that, I’m going to show up to work. Sometimes, I need to engage in my own grounding and coping skills in order to do that well.

Is any of this a problem?

Some therapists would certainly say so. There have been viral conversations making the rounds lately asserting that therapists shouldn’t even have water in their sessions. The argument is that it’s distracting and therefore detracts from the client’s therapeutic work. I find it absolutely wild that therapists (most of these arguments come from fellow therapists) can preach self care all day long, but then shame their colleagues for meeting basic human needs.

Because what I have found, more often than not, is that my authentic presence in the room isn’t a distraction.

It’s permission.

It subtly shows my clients that they get to be human too. It’s really common for new clients to feel a bit awkward and stiff. It can be intimidating to come to therapy. Some people are anxious about sharing their story to a stranger. Some people think they have to “do therapy right.”

But a few sessions in, their affect changes. They start to soften, speak more authentically, and open up more. That’s not just because of my verbal rapport building skills. My own body language and behavior in the room is part of my rapport building.

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Think about the last time you got to sit down and catch up with a close friend. Were you just sitting there, back straight in the chair, feet flat on the floor, staring at each other and doing nothing else? I mean… I doubt it. Maybe you had coffee or wine or margaritas. Maybe you were lounging on the couch or sitting cross legged in your chair or leaning on a bar stool. You were probably moving around a little. Laughing. Expressive. You were human. You were comfortable.

Therapy is very different from friendships. But we can still offer a general presence that feels comfortable. By showing up as human, I’m silently giving permission for my clients to show up as human too. And they do. They start doing their sessions with me while on a walk. They start sitting outside on their porch. They bring their own coffee. They introduce me to their dog. They come into the office with snacks and rearrange all the pillows. They allow their own neurodivergence to show up without fear of judgment.

And they also start doing the work. When people are seen and accepted for who they are, all kinds of things can happen.

So if you find my approach unprofessional, overly casual, or GASP! unethical, go for it. I’ll be over here enjoying my Fidgety Therapists Club membership, while you suffer with dry mouth because you don’t allow yourself to drink water in a job that requires talking all day.

But if you’re also a Fidgety Human therapist, I hope this gives you permission too.

As always, thanks for reading.

Laura

Accreditation requirements and standards need to change. Academic bubbles need to be burst. Graduate courses and internships need to reflect the realities of today’s mental health field and prepare students to enter it. But honestly, I don’t see stigma and stereotypes and the gap between school and reality going away anytime soon.

So in the meantime, these are a few of the myths I have personally had to unlearn. Maybe you’ll chuckle at how naive I was at some of these (totally fair). But I’m guessing some of them will resonate, and if so, I hope my reflections can either feel validating or help you start thinking about myths that are still showing up in your professional world.

Myth: All your clients will like you.

This is one of those statements that was totally implicit, but still made a big impression on me. I don’t think any of my grad professors said that we should expect to get along great with all our clients. But so many of the examples, the role plays, the client stories etc. kinda made it seem that way. It was like we could look forward to having these big, beautiful light-bulb moments with clients on the regular. At the very least, we would have these genuine relationships with these lovely clients who all looked forward to their time of healing with us every week.

And sometimes, that’s all true. I have really, genuinely enjoyed most of my clients over the years. And as far as I know, they’ve enjoyed working with me. I have experienced many breakthrough moments with clients that were truly life changing.

But that’s just not the full picture. I’ve also been assigned to clients who wanted nothing to do with me. Maybe it was because I was their 12th therapist and they were just tired of the system shuffling them around. Maybe it was because they’ve experienced medical trauma or have been consistently misunderstood and dismissed by providers who were supposed to help them. And yeah, sometimes maybe they just didn’t like me. That’s normal too.

When we have this implicit expectation that all our clients are supposed to like us, and then they don’t, we can easily think it’s something wrong with our clinical skills, our approach, or even our character. And that might not be true at all.

The real lesson: Mutual respect and therapeutic efficacy is not reliant on natural affinity.

Bestie vibes aren’t necessary to do good clinical work. Stay open and curious about your clients’ stories and experiences. Lean into your ethics and professional values. Focus on providing excellent care for the reasons they are seeing you. You truly do not have to like them in a personal sense. And they don’t have to like you. You need to respect them and support them toward their needs as best you can. If you’re overly reliant on working with clients whom you could otherwise be friends with, it’s possible that you’re leaning more on your natural people skills than your clinical skills.

Myth: Don’t expect to make much money ever.

This myth exists for a reason. Therapists absolutely are chronically underpaid as a profession. The problem is when grad programs, employers, and other therapists tell you that you shouldn’t make much money, as if part of being a therapist is mandatory vow of poverty.

This is a job. You deserve to get paid for the work you do. And on top of that, it’s a job that requires advanced education, both soft and technical skills, and a lot of emotional labor. You should be paid a fair wage, not just whatever employers tell you is acceptable because it’s what they’ve always done. Warm fuzzies and the reward of helping others doesn’t pay the rent. It was really hard for me to get out of this mindset after working in nonprofits. But when I was a fully licensed therapist working full-time and still needed help paying my rent for several months… that broke me. After that, no one could tell me I was being selfish or ungrateful for daring to dream beyond $50k.

So yes, you certainly can spend your entire mental health career getting paid like shit. But you don’t have to.

The real lesson: Know your worth and fight for it.

There are more and more better paying options out there, and more ways than ever to have a healthy, diversified, and sustainable practice if you choose to go that direction. Advocate for yourself and, if you at all have the option, refuse the jobs that pay you a fraction of your worth. It will take our collective professions refusing a lot of jobs for it to meaningfully change. I’m not naive about that. But as much as it’s in our power, we need to try.

Myth: You have to “do your time” in awful jobs before getting to move up in the mental health world.

Back in the day… yeah this felt pretty true. But the field has changed a lot in the last several years. New grads are embodying their skills and worth a lot sooner in their careers than many of us did years ago, and are no longer putting up with horrible wages and treatment. This myth is definitely the sibling to believing you shouldn’t make good money as a therapist.

There is value in working in settings that are often considered the trenches: community mental health agencies, hospitals, nonprofits, detox centers, shelters, correctional facilities, etc. I shared a lot more about my own experience with my early career trenches work in this post. But the point is that you don’t have to do that if you don’t want to. There are other options. In many states, pre-licensed clinicians can start a private practice as well.

The real lesson: Focus on building a career that is sustainable for your life.

If you want clinical experience that can best be gained at a nonprofit, look for those jobs. If you like the idea of shift work that never comes home with you and PTO you can easily bank by working twelves, hospitals might be great fit. If you know you want to have a private practice, focus on either starting one or getting similar experiences at a group or outpatient clinic. Do what makes sense for you. Nothing else really matters.

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Myth: Couples therapy requires total therapist neutrality.

I definitely absorbed the idea, whether explicitly or implicitly shared with me, that therapists must be totally neutral in couples’ settings to be practicing ethically. Many of my students believe this too upon starting internships, so I know it’s not just me. I get where it comes from: not wanting to show bias toward one of the partners, giving them equal time to express themselves, etc. And some couples’ modalities do encourage as much neutrality as possible.

But total neutrality is not really that helpful in many cases. Couples’ issues aren’t usually 50/50. They’re 90/10, 20/80, and 60/40 all at the same time (you get the idea). We can give couples equitable time and attention in therapy without making everything exactly the same. As I actually started to work with couples, I realized that total neutrality often meant equalizing issues: one partner cheated repeatedly, and the other partner became dysregulated and yelled after experiencing a betrayal trauma trigger. When we act like reactive responses and deep betrayal (as examples) are the same, it can be deeply invalidating to one partner and enabling to the other. They’re not the same. They shouldn’t be treated the same.

The real lesson: Review modalities for what they really say, rather than what we’ve absorbed. And remember how important your clinical intuition is.

The thing is… many of the major couples’ modalities out there don’t actually teach total neutrality. EFT allows for therapists to side with one partner when there is an active negative behavior happening in the interaction cycle from the other partner. RLT absolutely allows for therapists to take sides, specifically when there is a power imbalance between partners. While the Gottman method encourages the therapist to be a neutral facilitator, they also acknowledge that total neutrality can feel like invalidation to a client if that neutrality means not acknowledging their pain.

All this to say- I don’t know where this myth actually came from. But you are allowed to lean on your clinical judgment and intuition within your chosen theoretical orientation(s). Beyond that, I personally don’t think most couples want total neutrality. They want someone who is real, authentic, and who can actually help them change. Teaching them basic “I statements” and stating that they both contributed to their problems without more nuance is basic and likely unhelpful therapy, at best.

Myth: Self-disclosure is always unethical.

General teaching was shifting away from the blank slate approach when I was in grad school. But it still had a lot of influence. As an early career therapist, I was very much nervous about how to respond to personal questions and struggled to determine whether any self-disclosure was okay. What I was generally taught is that self-disclosure doesn’t serve a clinical purpose and more often distracts from the client’s needs.

But this concept, if taken at face value, drifts into areas that just don’t make sense. A child client asks you what your favorite animal is, and you’re supposed to deflect? A client asks if you’re from the state you live in now, and you’re supposed to ask what knowing that answer would mean to them? Some questions are just questions. It doesn’t have to be that deep in a lot of cases.

The real lesson: Self-disclosure is a nuanced issue that can certainly be unhelpful and damaging, but can also be a clinical tool.

Self-disclosure is just not black and white. I wrote a whole post on this topic too, if you’re interested in a more detailed perspective and the ethical framework that guides my approach to self-disclosure, especially when it does get into deeper or more personal territory.

Self-disclosure is a topic that deserves individual reflection and development of your own professional ethic. There are many ways it can be helpful, and many ways it can be harmful. Take the time to consider your approach to therapy, the populations you work with, topics that you feel comfortable and uncomfortable disclosing about, clinical purposes of disclosure, etc. rather than painting every scenario with the same broad strokes.

My Therapist Resource Shop has tools for growing your practice, checklists and spreadsheets to keep you organized, and on-demand video trainings. Check it out!

Myth: Politics has no place in therapy.

This myth might feel less true for social workers, as social work has always been more intrinsically connected to policy and macro systems in society. But in a counseling program, where much more of my education was focused on direct therapy, there was definitely a rhetoric that we need to stay totally neutral when it comes to politics. Respect your clients’ values no matter what they are, leave political topics out of therapeutic conversations, and don’t show clients what your politics are. They don’t need to know, and to tell them would be a form of unhelpful self-disclosure. But since 2016, this formerly common professional value has changed significantly.

The real lesson: Therapy is inherently political.

Major issues in the political sphere now aren’t zoning codes and minor tax shifts. They are about human rights, human dignity, and human autonomy. I greatly struggle to understand how a therapist can abide by our professional ethics codes, genuinely respect the autonomy and dignity of clients, and yet continue to support the current administration.

On the micro level, clients need to be able to feel safe with us. If a client isn’t sure if you’d support their humanity in the voting booth, how are they going to share their most vulnerable trauma with you?

Does that mean we can’t work with clients who share different political views? No, it doesn’t. But I think every therapist has the right to pay attention to their internal wellbeing during sessions. We are people too. We have personal stories and identities too. If a client’s beliefs are really hard for you to sit with and are coming up in session regularly, absolutely take the time to consult with a supervisor or trusted peer about what you can navigate and what you simply can’t.

Beyond that, we have a responsibility to recognize if a client’s views are so different that we are struggling to avoid bias and give them the best care they can receive. It’s ok for this to be the reason to refer out. There are other therapists out there who can sit with this person with less reactivity and ultimately provide them better care.

On the macro level, policy affects mental health care in a myriad of ways. From how we work with insurance, to the rights our clients have in therapy, to how collective trauma and systemic oppression show up in therapy, to what resources are funded and which ones aren’t, to how Medicaid and Medicare changes impact therapy…. we can’t avoid politics.

Myth: Don’t trust anything that’s not an evidence-based practice.

EBP’s are the gold standard for insurance payers, in many agencies, and honestly in the practice of therapy in general (at least in the US, I can’t speak to any other countries). That standard impacts whether certain modalities are reimbursed by insurance payers, what practices get more air time in grad school, and who’s considered a legitimate therapist. And along with that has come a ton of bias against any practice that is not considered to meet the threshold for evidence-based and a general policing of techniques that don’t fit into this category.

The real lesson: EBPs exist for a reason, and so do other indigenous, spiritual, and cultural practices.

I’m all for rigorous research. It has given us meaningful frameworks for understanding and treating so many different mental health concerns. And I do agree that there are modalities that are considered the standard for treating certain mental health disorders for very good reasons, and that engaging clients with those disorders in other modalities without solid clinical rationale can actually do harm. I’m EMDR Certified. I’ve been trained in modalities like ERP and ACT. I have witnessed their benefits countless times.

AND

EBPs have become the standard for all therapy without a lot of discretion, at least on the payer side. It doesn’t matter who you’re working with. Sprinkle some CBT language into the documentation and insurance will likely approve the claim. But that has nothing to do with whether that particular modality is clinically helpful for the individual client in front of you.

Many EBPs utilize a lot of the same interventions, and they just get different names based on which one you say you’re using. Some have a strongly skewed lens based on white, heteronormative patriarchy. Sometimes what we can finally start explaining through research is already well known to indigenous communities and healers.

And what I see most commonly now is that the interventions many of my clients need aren’t therapy at all. People need safe housing, livable wages, affordable costs of living, supportive communities, psychological safety, sunshine and nature, healthy boundaries, enough free time to engage in things they enjoy…. basic human stuff that has somehow become a luxury.

What I’ve learned after 11 years and well over a thousand clients is that sometimes people really benefit from specific therapeutic interventions. Sometimes a little creativity and a lot of therapeutic rapport go a long way. And sometimes what they need just can’t take place in the therapy room. We need to recognize all of the above.

Myth: If you’re already an emotionally intelligent people person, you’ll automatically be a great therapist.

If you’re already good with people, you’ll be a good therapist. Just keep being yourself and throw in some theories. You’ll be fine! I was on the receiving end of this one. I was a natural as a student. I got a lot of praise and encouragement in grad school. I won awards. And in my early years, that ended up feeling like I actually got less support and mentoring as a result. I was supposed to just “get it.”

But this isn’t a profession that you can just step into, no matter how good you are with people.

The real lesson: This profession requires learning clinical, interpersonal, and often business skills. And it takes a lot of learned grit.

It’s natural and often really powerful to integrate our authentic personalities into our therapeutic approach. There’s nothing wrong with that. But it can’t be the only thing we rely on.

Intentional clinical skills and therapeutic interventions are the difference between getting coffee with an empathetic friend and actual healthcare.

No matter how natural you are with people, there is still so much to learn. We need the clinical skills: the theories, the interventions, the treatment planning, documentation, crisis management. All the things. And we to develop our own interpersonal flavor as therapists, blending our personality with our approach to clients, and recognizing when and how to shift interpersonally in order to connect with clients. We also need to recognize when the aspects of our personality that have been deemed as “people skills” might actually be maladaptive responses from other parts of our lives that can impede our clinical judgment, but that’s a whole other conversation. But it’s one reason why we need to do our own healing work and not just rely on how we naturally show up.

Beyond the clinical skills, we also need institutional knowledge and/or business skills. This is stuff like how insurance billing works, which psych hospitals are tolerable and which ones are horrible in your local area, your state’s Medicaid laws, how to market yourself, all the business licenses and registrations you need to run a legal practice, how to write up all your own consent forms, how to effectively consult with a psychiatrist, how to work two or three calendars together when you’re freelancing at multiple groups…. it goes on and on. And all of that is the stuff that you just have to learn by being out there in the field and doing it. This is when leaning on supervisors, consultants, and mentors can be really helpful too, as most of us have developed institutional knowledge by making a LOT of mistakes.

And then the grit. This comes back to the first myth that all your clients will like you. Most of our work environments are not easy. That’s just not the nature of the work we do. You’ll encounter vicarious trauma, primary trauma, bureaucracy, broken systems, insurance denials, chronic short staffing, unhelpful or even abusive managers, clients who are rightfully angry at a system that has failed them and you’re the face of it at the moment, the pain of systemic oppression and problems that therapy will never be able to solve, and the general disillusionment of “wtf am I doing this for?” Maybe you’ve already run into some or all of those things.

That grit can’t be taught in a classroom. You have to come back and remind yourself every day why you do this work. That doesn’t mean you have to do the same work your whole career. I am a huge proponent of therapists advocating for themselves and getting out of environments that are organizationally abusive or just aren’t the right fit. I also know that you can love your work as a therapist. You can absolutely build a career that is rewarding, meaningful, and sustainable. But it’s still heavy at times. We work with human suffering. You can’t go anywhere in this field and expect easy.

Final Thoughts

If you made it all the way to the end, thank you. And I hope this resonated and got some conversations going, whether with your colleagues or in your own reflection. As always, thanks for reading!

xo

Laura

First: how do I define my specialty and niche?

I’ve got a whole post on that here. It breaks down the three factors that should be considered when defining your niche: clinical skills (this is technically the specialty part), populations, and community need/demand. The combination of all 3 is your niche.

You might have one specialty and multiple niches…

• anxiety (specialty)

• women with postpartum anxiety (niche)

• teen athletes with performance anxiety (niche)

Or maybe one niche with multiple specialties….

• LGBTQ+ adults (population niche)

• couples work (specialty) with LGBTQ+ adults

• family therapy focused on parenting (specialty) with LGBTQ+ families

Second: not all specialties are created equal

The reality is that mental health trends, marketing, mainstream culture, updated research, and practicality all play a part here. That strictly Freudian psychoanalysis specialty just doesn’t hit like it used to. Other specialties are just impractical. For example, I think equine therapy is an incredible specialty. I’m not sure how practical it is in New York City (if this is a thing, seriously please let me know!).

This is where understanding the major trends in therapy demand can be helpful. You want to define a niche that you’re skilled in and passionate about. But if you’re a solo practitioner funding your own continuing education and marketing, it’s also wise to have a specialty (or two or three) that will bring you a higher return on investment.

The most searched therapy specialties of 2026

I wrote down what I thought would be the most searched therapy specialties so far this year. And then I asked ChatGPT to give me the actual search results. And honestly, I felt pretty validated! Almost everything I wrote down was in the top 10. And the ones that weren’t were almost all in the “up and coming” list, which I personally think can be even more valuable as the market is over-saturated yet.

In general, current specialties and demand in therapy is being driven by several factors: the ongoing post-pandemic mental health surge, the huge expansion of telehealth services, identity based care and cultural matching becoming a much higher priority, and increased awareness of therapy language and specialties. Potential clients are more aware of their needs, more informed, and more selective in their therapist search than ever before.

Here’s the top 10 and my personal commentary:

1. Trauma and PTSD

Trauma and PTSD is not a “new” niche by any means. But trauma has been at the top of the list for several years and continues to hold the top spot by a large margin. There continues to be increased awareness of what trauma actually is and how it can manifest in one’s life, there is a strong referral pipeline for PTSD, and many trauma modalities work well with telehealth. Many of the more popular modalities right now, such as EMDR, IFS, and psychedelic assisted therapy, are a good match for trauma work.

2. Anxiety, burnout, and stress

The driving population for this niche is currently high performing adults. The pandemic changed everything about how we relate to our workplaces. For those nearing retirement, the whole system changed right when they thought they could coast. For those mid-career, there have been huge adjustments to adapt to. And for those whose careers started in or after 2020, their reality is totally different from what they were taught it would be. No matter what: anxiety and burnout.

3. Couples

Couples will always be an in-demand niche. There is always a need and never enough skilled, specialized therapists to do the work. I do think there’s a particular flavor of couples’ therapist who can do really well right now, though. And that’s the therapist who is hands-on, not afraid to be an active participant in the work, and who clearly has advanced training in couples’ modalities.

Modern couples aren’t interested in bland, neutral-to-a-fault therapists who teach them I statements. They want to address power imbalances and the reality of what’s happening in their relationship, and they want more in-depth skills to help them maintain their progress long after therapy.

4. Perinatal and women’s mental health

The referral pipeline from OBGYN offices has increased significantly as awareness around perinatal mental health has skyrocketed. But more importantly, women are recognizing that their symptoms are not “normal,” they deserve to get help, and they’re tired of being dismissed. When they’re ready to talk, they want someone who gets it.

5. Identity-based and culturally competent therapy:

This has always been important. But the last 10 years, since Trump first took office, has escalated the cultural and political divide faster than any era in modern history. To many clients, therapists who hold certain identities may not feel safe. They want to know whether they should even attempt to trust a therapist right off the bat.

In addition to that, having at least a couple of shared identities between therapist and client has been shown to increase positive outcomes in therapy. As more people are aware of this, they’re searching for it more specifically. And telehealth has expanded access widely, so clients have the opportunity to search for a therapist who shares identities with them.

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6. Grief and loss

This is another niche that will always be in demand. Grief is a universal human experience, and one I personally believe every therapist should work to be competent in, as grief can hit anyone on your caseload at any moment. The demand for grief work specifically has increased significantly since the pandemic, as so many people experienced loss during that time.

Related to grief work, one of the niches I think is up and coming is adult family estrangement. As I mentioned above (and it’s pretty fucking obvious), the political divide of the last 10 years has impacted American society in every way imaginable. Conversations that could be patched over or left out of Thanksgiving dinner just can’t anymore. People are setting more boundaries with family, going no contact, and struggling with the potential need to take bigger action.

7. SUD and addictions, particularly process addictions

This is one of two on the top 10 I didn’t guess. Process addictions, such as gambling, online gaming, porn, and social media, are gaining a lot of traction. People are both gaining awareness of the potential harm of process addictions, while also living in a society that actively tries to reel us in. These addictions have become significantly more common in searches than substance use.

8. Chronic illness and pain

The population is aging, many people feel disillusioned by the medical system, and the need for non-pharmacological treatments for chronic illness and pain is massively growing. I also think that more people are becoming aware of the impacts of their chronic illness and/or pain, and are refusing to “just take it” anymore. There is also an increased referral pipeline from medical providers who recognize the benefits of therapy as part of a chronic illness/pain treatment plan.

9. Kids, teens, and family therapy

Another specialty that is not new by any means and will always be in high demand. Seeing kids can be logistically tough: it often means after school hours, the need for office space and equipment for play therapy, and working with less than cooperative parents. But if you’re passionate about it, you’ll never be out of work. Teens seem to be the fastest growing population in this area, which I think is probably attributed to growing mental health awareness amongst younger Gen Z and Gen Alpha, and unfortunately, a growing youth mental health crisis.

10. Corporate and executive mental health

This is the other one in the top 10 that I didn’t guess, but it makes sense. A lot of this work is a therapy/coaching hybrid, which yes, can blur some clinical and ethical lines. But if you do it well, you can find yourself in a great spot. This kind of therapy works well with employer sponsored mental health programs, and is gaining in popularity partly because more therapists are branching out into coaching.

I’ve added a couple new products to the Therapist Resource Shop!

Other niches I think are up and coming:

- Late diagnosed neurodivergent adults

I was really surprised that this wasn’t in the top 10. As awareness of neurodivergence has skyrocketed, and both clinical and lived experience information is mainstream, sooooo many clients have come in with questions around their own neurodivergence. What I see the most amongst therapists in my little bubble (which is several hundred clients because of all my supervisees), Autism and ADHD are definitely the big ones here. I think it’s really important to have a strong understanding of the neurodivergent experience as well as the neuroscience. It’s also essential to tailor your interventions to your client’s unique way of processing. It’s time to go way beyond post-it’s and alarms for ADHD.

- Psychedelic work

Maybe this one was grouped in with the trauma niche, totally possible. But I think psychedelics are still up and coming, and will only continue to get bigger. These modalities are not just for trauma. They are being shown to be effective for treatment-resistant depression and other mood disorders. In addition to specifically clinical applications, many people are seeking more holistic and spiritual care as part of their overall healing.

- Men’s mental health

There is increased awareness of the need for mental health support, and the consequences of emotional intelligence deficits, among men. But some of the old stigmas still remain, making it hard for men to find a great therapist to connect with. If you can speak really well to this population, have both identities and lived experience that your niche within this population can relate to, and can approach therapy in a modern, non-traditional way, you can make a huge impact here.

Final Thoughts

What do you think? Would you have guessed these as the top specialties too? Did any surprise you? What are you noticing in your own community? Would any of these specialties influence your own niche if you’re in the process of defining one? I’d love to hear your thoughts.

As always, thanks for reading.

xo

Laura

1. Primary Trauma talk with Therapist Resource Network

I’m excited to be speaking on navigating primary trauma as therapists as part of Therapist Resource Network’s Burnout series.

Thursday, March 26
1pm ET/10am PT
Register here for free

Thankfully, vicarious trauma, burnout, and compassion fatigue are getting a lot more attention in the mental health community. But many of us still don’t know how to process an experience of primary trauma in our workplaces: things like a client death, threats, assaults, contentious court case involvement, and unsafe work environments. That’s what we’ll be discussing. If this is a topic you’d love more info on, I hope you can join us!

Btw, the Therapist Resource Network is an awesome organization, completely focused on supporting therapists. They offer workshops, support circles, and grants for therapists with urgent financial needs,

2. Newly Licensed Therapist Group

I host a monthly group for therapists who are independently licensed, but want to connect with other therapists, would like more support, or wish they still had access to a supervisor every once in a while. We talk about anything from cases to practice building to navigating life as a human who works as a therapist. Groups are pay what you can, and totally okay if that means free. The group meets on a drop in basis, but I do ask for RSVPs each month to ensure we have enough participants to meet. If you’d like to be added to the email list for reminders and to attend, please email me at Laura@ivoryandpine.com.

Next Groups:

Monday March 30 at 12pm MT/ 2pm ET on Zoom

Monday, April 27 at 12pm MT/2pm ET on Zoom

3. Revolutionary Practice Summit

Not my event, but I’m very excited to be attending the Revolutionary Practice Summit May 3-7, 2026 in Palm Springs! The summit is all about integrating alternative and holistic therapeutic healing methods into your clinical practice. I’m drawn to a lot of the speaker topics, and really excited to learn how integrate these methods into my practice. As a therapist who plans to stay in Therapist World and never become a life coach, this has been a big question mark for me for years. Hoping that changes by the end of this summit. Plus, it’s happening one session at a time! I’m so pumped to not have to pick and choose. Spots are still available as far as I know. If you’re going to, let me know! I’d love to connect.

Because of that, I get questions about what those jobs were like sometimes. And I’ve been reflecting on my early work experiences a lot lately in general. Was the clinical experience worth it to start in the trenches?

I don’t really have an answer to that question. I certainly am not saying that new grads need to take the same path that I did. I am grateful that early career therapists have more options than I did. And I’m also grateful for my individual experiences, for better and worse. If you’re curious about what those jobs would be like, maybe this will give you some ideas. And if you’re a seasoned therapist with a similar career history, maybe you can reflect with me.

The TL:DR of my first few jobs

My first job out of grad school was at a psychiatric hospital in the intake department. My job was to review clinical information sent to us by ED’s all over the state about patients who needed inpatient care, and decide if we could take that patient on one of our units. When patients were accepted and finally arrived at our hospital, I also assessed them and got them up to the unit. We often admitted 15-20 patients a day.

My second job was in an ED of a regular hospital. Now I was on the other side of inpatient admissions. I assessed patients who were brought to the ED and determined to need a psych or SUD eval. I wrote up all the clinical info that psych hospitals would later review. And if my team determined we needed to refer the patient to a higher level of care, we’d then start the search with inpatient units and detoxes all over the state if necessary. Meanwhile, we were monitoring and checking in on patients during an often long stay in the ER.

My third job was at a nonprofit on a multidisciplinary, wraparound team, called an ACT team at my agency. All of the clients in our program had severe mental illnesses and experiences of chronic homelessness. Some were unhoused at present, most had severe substance use concerns, and many had comorbid chronic medical issues. The vast majority of my therapy was done in clients’ apartments or in the community somewhere.

All of that work involved constant crisis management, assessment of clients with very acute needs, frequent experiences of vicarious trauma, and somewhat regular experiences of primary trauma.

Pro: I got really good at biopsychosocial assessments, documentation, and diagnosing very quickly

I did assessments all day everyday for a solid two years. So before I even got independently licensed, I was very well versed in doing biopsychosocial assessments, case conceptualizations, and identifying nuanced diagnoses and rule-outs. I had the opportunity to interact with people with all kinds of different concerns and diagnoses, and learned what methods of treatment could be most beneficial for them. These are all highly useful and versatile skills that I have used ever since.

Con: I didn’t get to dive into a lot of different therapy modalities

I didn’t do a lot of one-one-one therapy or keep clients for any length of time my first few years. It was all crisis, in and out. At the nonprofit, I did have long-term therapy clients and deepened my skills then. But I didn’t really get to fine tune my 1:1 therapy skills, theoretical orientation, and clinical approach until I was a few years into the field.

Pro: I had a lot of real time, in person support

My first two jobs had a similar setup. We saw patients in intake rooms or ED rooms, and then would return to our open group office to document and do the rest of our tasks. As a result, if I had a question, there was almost always someone right next to me to ask. As I got more seasoned, I could also be the person to answer those questions. It allowed me to improve my skills in real time, all the time. We supported each other and worked together.

Con: I was greatly underpaid, equal to or more than in most private practice settings

No mental health job pays enough. But agency and nonprofit salaries have a reputation for being some of the lowest, and that’s pretty accurate in my experience. I’ve been on Medicaid multiple times as a working, licensed therapist. I’ve struggled to pay my rent on a full time mental health salary. I felt devalued and experienced increasingly low morale. My body, mind, and relationships were all suffering because of my work, and yet I still didn’t make a truly living wage. This certainly isn’t unique amongst therapists, unfortunately. But sometimes going straight to private practice settings can improve income potential earlier on.

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Pro: I got very used to intense situations and crises

Naked, high on meth, aggressive, and jumping onto moving vehicles… no problem. I’ve seen it before. Psychotic and masturbating right in front of me? Yeah that’s happened too. Threatened me with knives? Yup. Angry, rather scary individuals to whom my client owed money at the door during our therapy session? Wouldn’t be the first time.

I feel very confident supporting both my own clients and my supervisees through pretty much any client crisis. I’ve seen it all, and nothing in mental health can really scare me anymore. I’ve seen plenty of therapists, including supervisors, become highly dysregulated and anxious in a client emergency. I can stay calm and grounded.

Con: I got very used to intense situations and crises

I can genuinely say I’m calm and grounded in a crisis now. But that’s because I have several years of distance from doing that every day. The desensitization that I developed out of necessity impacted me for a long time. I was cynical, jaded, and exhausted. 7 years after graduating, I was so burned out that I just had to stop providing therapy. It was a full year before I could start seeing clients again.

Pro: I gained a lot of institutional knowledge

My early jobs taught me a lot about so many things beyond providing therapy: community resources, grants and government funding, mental health levels of care, working with insurance, legal issues in mental health, psychopharmacology, concurrent psychological and medical conditions, substance use, withdrawal symptoms… all knowledge that I still use all the time with both colleagues and clients.

Con: It took me a long time to stop seeing the worst case scenario in everything.

Working in high acuity settings gave me a front row seat to the worst of humanity. I don’t mean my patients. I mean the people and systems that deeply, horrifically harmed them and often continued to oppress them. I spent a lot of time in dark places, literally and in my own mind. I suppose that being in these sectors of mental health gave me a serious dose of reality; one that I could never forget. That has given me some wisdom. But it was also incredibly discouraging and disillusioning at times.

Pro: I made some lifelong friends.

I made some of my closest friends through these jobs. Were we trauma bonded? Probably! But at the end of the day, we always knew we had each other’s backs. We laughed, cried, advocated, worked, and grieved together. And those kind of bonds are not easily broken.

By the time I was ready to start a private practice, the idea of working alone didn’t bother me. I felt comfortable with the broader network of professional connections I had made over time, and I knew I still had those close friends in my corner, at and outside of work.

Con: My mental and physical health is still recovering from that season of my life.

My body was majorly impacted by high acuity jobs in ways that still affect me now. I gained a lot of weight, experienced chronic cortisol spikes that resulted in adrenal fatigue and other physical issues, and relied on take-out and screens as coping skills. I experienced flank pain and discomfort for over a year that was written off by doctors as stress. And because I was so overworked, I believed them and ignored it until I was septic due to a kidney that had literally died in my body while I just kept working. I met criteria for PTSD during much of that time.

I took a year off, like I mentioned. And I got pregnant almost immediately, which was good and beautiful! But also meant that my body didn’t actually recover during that year - I just had to adapt to new stress and physical changes. I’ve never been able to totally switch careers or just stop working long enough for my body to heal, so it hasn’t.

Final Thoughts

If I could do it all again, I don’t know if I would. It’s impossible to distinguish between the incredibly negative impacts on my life and the people, paths, and relationships that led me to where I am today. I suppose I’m grateful I don’t have to do it again and can just look forward.

If you’re in a position to choose, no judgment from me if you go straight to private practice. There are other ways to obtain the knowledge I gained by getting thrown to the wolves, and you’ll likely be able to take care of yourself much better than I did. That is incredibly important in this field.

If you’re not in a position to choose and these jobs are all that’s available to you, it’s going to be okay. It’s going to take a lot of grit, resilience, and support. But remember how much it has already taken to get this far. It will not always be like this, and you will be a wiser clinician for it.

As always, thanks for reading.

xo

Laura

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“Optum has performed a subsequent analysis based upon Oct 2025 through Dec 2025 paid claims; the detailed results are attached in the updated Psychotherapy report. The analysis indicates that the percentage of high-level codes billed is still greater than other providers in your specialty.” They then notes that they’ll keep an eye on my billing and may follow up (if I don’t get in line) for further “validation and education.”

The updated Psychotherapy report indicates that they actually reviewed 12 claims. TWELVE. And all of them happened to be billed 90837, rather than their expected percentage of 4.4% 90832 (30 min) and 15.5% 90834 (45 min) and 80% 90837. Are these actual averages or just arbitrary numbers they’re throwing out? Who knows. But just based on their analysis of 12 claims, I billed 90837 3 too many times. Based on the difference between my personal reimbursements rates of 90834 vs. 90837, 3 claims is a difference of anywhere from $30-60, depending on which states they were looking at.

This is what Optum considers a problem.

And when they state “specialty,” they don’t mean my actual specialty. They just mean psychotherapy. They don’t differentiate between EMDR for PTSD and play therapy for a 4-year-old. So when they say that my percentage is too large, it’s because they’re averaging it in with providers who do only bill 30 minutes, perhaps because they work with children who have short attention spans, or work in integrated care where they’re only allotted 30 minutes, etc. 90837 as a baseline therapy code is absolutely a reasonable standard of care for any therapist who sees adult clients in individual therapy, and frankly isn’t enough time in many cases.

Further, they remind me of the criteria for billing 90837:

1. face-to-face services with a patient and/or family member: I always meet directly with the client. Family members are present very rarely and always with the client, not instead of. So I’m above the minimum here.

2. patient must be present for some or all of the service: right, so therapists who may be billing 90832 and then meeting with parents for free could actually be billing 90837, seeing the child for 30 minutes, and seeing the parents for the second half. Because I work with all adults, my clients are always present for the entire session. Again, above the minimum.

3. in reporting, choose the code closest to the actual time (i.e. 53 minutes+ for 90837): yes, all of my notes list the exact start and end time, and they’re always at least 53 minutes. Above the minimum again.

4. Documentation supporting medical necessity: surprise, I do that too! When my clients have multiple major mental health diagnoses that are severely impacting functioning, and psychotherapy is by far the most cost effective way to help them not need higher levels of care, I’d say that’s medical necessity. In fact, that’s not my definition of medical necessity. That’s their definition of it.

Thanks for those reminders.

So what they’re really saying is… I’ve been taking too much money from them for services that meet or exceed the exact criteria of what they require for what I’ve been billing. Despite the fact that I’m doing my job exactly right, they would like to remind me to decrease the standard and quality of my care so that they can extract even more money from me, one single therapist whose gross business revenue is only about $130k, and increase their billions in annual profits at my expense.

Optum, you and all the other insurance companies can fuck right off. Audit me when you have actual evidence that I’m doing something wrong.

But there is also growing awareness in the profession and in the mainstream population of the limitations of the DSM and critiques of the system it has helped create. These critiques range from the biased perspectives that contributed to the DSM, to frustrations with its fused identity to insurance claims that often limit access to care rather than improve it, to the narrow and incomplete views on what qualifies as pathology while simultaneously over-pathologizing the human experience.

So what should we make of diagnosing? Is it truly so important for new therapists to learn? Is this just the way it is? Is there another way to look at it?

Like most things in mental health, I don’t see diagnosing as a black and white issue. It’s not solely good or bad. It’s not as simple as accurate or inaccurate.

I try to take a pragmatic view on diagnosing. It’s entrenched in the system we work in. We can’t fully avoid diagnosing, even if we completely oppose the whole system. So I generally think it is much better to be well educated and skilled in this area than to pretend it doesn’t exist, even if you run a cash pay practice your whole career. But I also think that being overly invested in this particular brand of diagnoses and psychopathology can do a disservice to our clients and our understanding of human psychology as well. For me, it all comes down to this question: when is having a DSM diagnosis beneficial for the client?

I’ll break down how I determine this for the remainder of the post. Please understand that these are my views alone. I have drawn from 10+ years as a therapist immersed in this world, from my education, and from others’ research. Many therapists have more expertise than me, and I by no means claim to hold the “right” view on diagnosing. I hope this post can simply give you some food for thought.

A little more on critiques of the DSM

If you are unfamiliar with the origins of the DSM or why it might be critiqued by professionals in the field, here is a quick synopsis.

The DSM was originally created in the 1940s out of the need to classify disorders affecting military veterans in the WWII era. The first two editions were largely based on psychoanalytic (aka Freudian) theory and early efforts to gather data on mental illness to standardize language, such as the 1918 Statistical Manual for the Use of Institutions for the Insane. Pretty bleak. The first edition of the DSM was published in 1952 by the American Psychiatric Association. First key that it might be missing some data - American. The DSM is not a classification system based on global data.

Early editions were not really based on research at all, but rather on prominent theories of the time. And as mentioned, the first populations to be studied were veterans, who were almost exclusively men in the two world wars. Academic research contributing to the DSM has generally been done by white male academics in privileged university settings, studying young white academic men who were also in those privileged university settings.

The DSM-III, published in 1980, introduced a more evidence and research-based approach. This was probably the biggest shift from one edition to the next that we’ve seen with the DSM. That research-based approach has gradually evolved to what we have now. Today, the DSM-5-TR is a 900+ page manual covering both categorical and dimensional diagnoses. That being said, it is still far from perfect. While many improvements have been made, the reality is that the DSM is based in the same western, patriarchal, white-centered, cisgender and heterosexual-centered roots as many of the other facets of our medical system.

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When does getting a diagnosis right matter?

First, let’s define what I mean by “getting a diagnosis right.” By this, I mean identifying a DSM diagnosis that aligns very closely with a client’s symptoms and lived experience. I do NOT mean having a complete understanding of the true etiology and/or manifestations of a person’s presenting concerns, symptoms, or personality patterns.

This is an important distinction, because we can’t assume that defining a DSM diagnosis means truly understanding the entire picture. It’s a relative standard. Sometimes, DSM diagnoses do fit well with a person’s lived experience. Other times, there simply is not a named diagnosis that truly describes what someone is going through. Or perhaps the person is going through human experiences that shouldn't be pathologized at all, but would still greatly benefit from therapeutic support.

My basic rule of thumb for when getting a diagnosis right matters is this: if the specific diagnosis will have a major impact on the client’s care, make sure it’s as accurate as possible.

The right diagnosis might benefit the client through increasing their options for care, supporting accommodations, tailoring treatment approaches to the client’s needs more effectively, or by providing them with clarity and validation of their lived experience. It might also benefit the client simply by providing the information necessary to get their services paid for, although I would argue that in many situations, getting it exactly right is not necessary for this purpose.

Some examples of “getting it right” situations:

• The client is specifically requesting diagnostic clarity.

• There is a treatment approach with significant research and efficacy for a specific diagnosis, and having that diagnosis will inform treatment effectively.

• The client is also in need of a medication evaluation and/or management, specifically if a change in diagnosis would also change the med regimen or prompt other interventions.

• Most accommodation requests: IEPs, FMLA, SSDI applications, any work accommodations, etc.

• If the client needs a particular diagnosis to qualify for other interventions that would benefit them

In these kinds of cases, diagnostic data can be a significant informant of how to move forward with treatment. And if that treatment is genuinely going to benefit the client and make a significant difference in their life, we should do our very best to get it right.

Getting it right means diving into the client’s symptoms, history, past trauma, motivations, exception conditions (when does this not occur?), frequency, duration, and onset of symptoms; family and cultural history, medical background, etc. It means comparing and ruling out diagnoses that are similar to choose what specifically aligns with the client’s life and current presentation most accurately.

When does the diagnosis not matter as much?

If the diagnosis will not meaningfully affect treatment or the client’s access to care, or if particular diagnoses could actually harm the client, it might not be essential to match symptoms up exactly to the DSM. This might mean that you don’t diagnose at all, if you have that freedom. Or it could mean that you don’t need to stress about getting it exactly right: all the subtypes, specifiers, severity, rule-outs, etc. You may be fine getting the diagnosis in the right ballpark simply to satisfy insurance requirements.

A few examples of this kind of situation:

• The client is not using their insurance benefits for therapy and you both have a good idea of their presenting concerns and clinical needs, whether they have an exact label or not.

• The client has experienced healthcare trauma in the form of receiving stigmatized and potentially inaccurate diagnoses in the past, being overly pathologized, or getting dismissed by healthcare professionals.

• A particular diagnosis would negate the client’s cultural background, lived experience, and/or values. An example here is a client who speaks about supernatural or paranormal experiences, and immediately giving them a psychotic diagnosis, rather than assessing all other pieces of their background and leaving space for the possibility that they have actually had those experiences.

• The diagnosis, even if accurate, won’t make a big difference in the client’s life. An example here is an adult who suspects they are autistic but has never been diagnosed. If the client isn’t planning on requesting accommodations or pursuing other treatment options as a result of getting an official diagnosis, do they truly need to be referred to psychological testing, especially if they would have to pay for it out of pocket or simply don’t want the assessment? I would defer to the client’s preference and autonomy and not push for a formal assessment.

• The client is sort of in between a few differential diagnoses. But regardless of which one is most accurate, the treatment approach and potential helpful medications (if applicable) remain the same.

• The client’s diagnosis is just there for insurance purposes. Perhaps it’s a reported diagnosis from the client’s history, or one that is well managed. Whatever the case is, the diagnosis is not really the client’s presenting concern.

In these cases, I assess the client’s symptoms and history to get to a general diagnostic category that fits, such as depressive disorders or anxiety disorders. After that, I tend to see what the minimum criteria is for an applicable diagnosis in that category. I find what fits best and move on.

If the client could maybe fit the criteria for two different diagnoses, I go for the easiest one. Find the lowest common denominator. You may not need to dive into all the history and etiology and nuances in order to provide an accurate diagnosis and effectively work with the client. Basically, don’t spend all your mental energy on something that the client doesn’t actually need or care about that much.

Is this morally ambiguous? Am I documenting inaccurate data?

I’ll answer the second question first. I don’t document inaccurate data or make up symptoms. I simply pay attention to the client’s experiences, history, and symptoms and recognize that different people use different language to describe their experiences. Maybe I need one more criteria to make GAD work, and today I realized that my client does tend to be a little restless and fidgety in session. Sounds like “restlessness, feeling keyed up or on edge” to me. Do I need to dive deep into a particular assessment or grill the client for the “right language” to see if the client’s experience of restlessness is clinically significant enough for me to add the symptom? Nah.

First of all, the vast majority of diagnostic criteria in the DSM are relative and/or subjective. Second, we just discussed a few of the reasons why the entire diagnostic system is pretty flawed in the first place. It’s not pure objective science by any means. Third, if that tiny detail is the difference between the client getting a diagnostic code that requires insurance to cover their mental health services or not, I’m giving them the diagnosis.

This leads back to the first question. Is this behavior morally ambiguous? In my opinion, no. You have to make your own decision based on your professional ethics and risk tolerance. But this is my thought process.

We (mental health professionals) are stuck in between two completely opposed systems: clinical ethics and a profit-driven insurance system that does not give a shit about any patient ever and makes numerous billions annually off of our collective sickness and individual providers’ labor. I know where my loyalties lie, and I have zero issues being a little flexible with a diagnosis so my client can continue to access care. It’s all about the translation from the work that happens in session to the clinical language necessary for documentation.

Personally, I am well aware of the exploitative nature of the therapist-insurance payer relationship. I continue to take insurance, and I have my own reasons why, but I do not pretend that it is a mutually beneficial partnership. They treat us with absolute contempt, disdain, and disrespect. Why should I stress over documentation that will be reviewed for 0.2 seconds 95% of the time?

Yes, my documentation is always prepared for audits. But I understand that the audit process is based entirely on documentation meeting their arbitrary standards for compliance. They don’t call the client to testify whether their symptoms exactly line up with what I wrote. They don’t ask the client if the treatment they’re receiving is medically necessary and why. It’s all just a complicated, rigged game. I simply play accordingly. I give them the documentation they want. My clients access their benefits. I provide them with medically necessary clinical care. I sleep just fine at night. Take that however you like.

What should new therapists focus on learning?

I recognize that you may need to learn additional or different information for the purpose of licensing exams. This is what I would focus on if you’re a new clinician or student who has been thrown into the real world of clinical work and is feeling overwhelmed with the amount of information to learn.

• Memorize general diagnostic categories and key symptoms that can help you quickly get to the right ballpark when you’re assessing a new client. You can always review the DSM criteria in real clinical settings. You don’t have to memorize those 900 pages.

• Focus on the most common diagnoses seen in your work setting. Yes, of course, your work setting will likely change at some point and you’ll need to expand your knowledge base. But when you’re brand new, focus on what matters most right now and get comfortable with that.

• Develop your own “decision tree” to help you determine how much energy you need to spend on a particular client’s diagnosis. You might approach it in a way that’s similar to what I’ve discussed. You might prefer your supervisor’s approach. You might develop something totally different. But give yourself a critical thinking framework to help you navigate this area. It’s easier to have general guidelines than to try to memorize the answer to every possible circumstance.

• If you do work in a setting where accurate diagnoses are a common part of the work, honestly don’t stress. You’ll learn so much from your colleagues and get really good at this stuff doing it every day. Just continue to absorb everything that you can.

Despite my obvious frustrations with the DSM, I actually love diving deep into complex diagnostic puzzles and figuring out a diagnosis that no one has been able to see for a client before. If you’d like to connect for consultation, supervision, or join a drop in group, reach out to me on my website.

Thanks for reading!

Laura

This post is for the therapist who wants to work in an outpatient, private practice type of environment, but isn’t sure about being a small business owner just yet. Some days, you think you could do really well as a solo practitioner and would love that autonomy. Other days, that sounds incredibly unstable and overwhelming. You’ve seen all kinds of ads to “be your own boss” by joining a big, VC backed company to help with credentialing, billing, and marketing. But you’re not sure if that’s all it’s cracked up to be either.

I can’t make your decision for you, but I can help you understand key factors to consider, various group practice structures (so you know what you’d be getting into ahead of time), and generally what to expect either way. Let’s demystify this process together.

Quick note: private practice type jobs are only one sector of the mental health industry. I plan to also do a post comparing various sectors of the industry beyond just this one area. I’m starting here because private practice jobs tend to be the most ambiguous in terms of structure, level of autonomy, and wages.

Key factors to consider

Working at a group or in solo practice can both be really rewarding, and both can be long-term options. You need to reflect on the specific factors that will make the biggest difference for you.

Legal Factors

If you’re an associate therapist working under supervision, the first thing you need to check is whether your state allows you to start a solo practice, because not every state does. There may also be laws around who can supervise you as a pre-licensed solo practitioner, which often ends up coming back to employment law. You always need to make sure you’re practicing legally.

Autonomy

Having autonomy over your caseload, schedule, and practice policies is usually one of the main factors that therapists are considering when choosing any kind of private practice setting. Obviously, a solo practice gives you the most autonomy. But, that comes with the most responsibility and potential for mistakes as well. Starting a solo practice means starting a business.

Ensure that you are ready to put the ongoing time, money, and cognitive investment into things like business planning, accounting and taxes, marketing and client acquisition, and administrative responsibilities. If you’re feeling overwhelmed by the idea of these tasks, that doesn’t automatically mean a solo practice is off the table. But I would recommend consulting with a business or private practice coach to get more clarity on what is going to be required to do this well. If you know you only have minimal time for these tasks, or you really don’t have any interest in owning a business, a group practice may be the better option for you.

Within the group model, there is still a wide range of autonomy offered. When looking at job listings, consider things like…

1. minimum caseload requirements: Does the practice require you to see a certain number of clients per week? Many do to help ensure that you’re working enough to at least cover the basic expenses your position will incur. But that requirement can vary a lot, and can impact your paycheck by more than just the number of hours worked, so make sure you’re clear on the expectations.

2. working hours: A remote or hybrid group might allow you to have total control over your schedule, but an in-office group might be more restrictive based on when office space is available. Some practices also require evening and/or weekend hours.

3. client assignments: How much control do you have over the clients who get assigned to you? Some practices do very tailored matching, others tend to just assign clients to whoever is available.

4. level of admin support: Is there an admin at the practice to take calls and inquiry emails, manage practice troubleshooting issues, handle billing, etc.? Or are you doing that?

While there are other details that can speak to levels of autonomy here, they all kinda feed into this general equation. The closer you are to functioning like a solo practitioner, the more money you should make. If you receive a lot of support and pay for fewer business expenses, you should expect the practice to keep more of the fee split.

Season of Life

Where do you want work to fit into your life right now? Do you want to grow a business? Do you want to just show up to work? Do you have the time to dedicate to running a practice? Do you need to learn a bunch of new skills before you could run a practice? Could joining a group first be a great way to learn some of those skills? Does it make sense for you to start your practice on the side while working a full time job, or do you want to jump in head first?

Ultimately, this is the kind of career that has to make sense with your life. It’s already hard enough to be a therapist. If you want to do this work for the long haul, you need to make your job work with your life as much as possible. Reflect on what that currently means for you.

Community and Support

Solo practice can be really isolating and lonely. For some people, that’s not an issue, and even welcome. For others, it’s a dealbreaker. With all of the remote work options, it’s important to remember that you can work at a group practice and still feel pretty isolated. It’s all about the individual place you work. There are also plenty of ways to get connected to your local therapy community if you’re a solo practitioner. But if your season of life is going to make it really hard for you to intentionally connect with others, and you want that, it might be important for you to look for a job with some built-in connection. And of course, if you are needing supervision, you need to prioritize that.

The downside of community is the drama. Oh yes, my friends. Group practice drama can be intense. You put a bunch of people in an intense, never black and white, people-oriented job together who don’t always know how to communicate the hard business stuff without taking it personally and phew it’s a lot sometimes. Team dynamics, turnover, and staffing concerns are easily the most stressful part of the job for group practice owners, and that stress can trickle down to the rest of the therapists when it’s not handled well.

Risk/Reward

When you’re the sole owner, it’s all on you. For better or worse. That means all the profits go to you, so there is potential for a higher income once you learn to streamline your expenses and maximize your revenue. You only have to worry about yourself, and that’s nice. Your admin tasks generally don’t get that complex, even if there are a lot of them.

All the mistakes fall on you too. The burden of getting clients is totally on you. You can’t rely on someone else to figure out where else to find clients if your Psychology Today profile isn’t getting any hits. If you can’t get clients, you don’t have a practice. If you mess up your taxes, the bill is yours alone.

For some, that risk is just too much to mess with, and that’s understandable. In general, if you’re at a group practice, the range of responsibility is more narrow. You assume less risk, because the group owner is assuming some of that risk for you. But your income potential only goes so far too.

Ethics

It would be great to be able to trust that any practice you work for will have solid ethics. But that’s just not true. The rise of venture capital and corporations in mental health have changed the landscape a lot in the last several years. I’m not saying that all the corporate mental health companies are bad. And I’m never going to judge a fellow therapist who needs to work at one. We gotta pay bills and eat. My general advice? Sleep with one eye open and your bag packed. You just never know.

Generally, a local clinician-owned group practice will hopefully be more clear about their values, and likely more aligned with your own values as a therapist. And that being said, they’re not immune to bad decisions either. People’s ethics and values can change when they are incredibly stressed, responsible for a lot of people, dealing with a lot of money, and things aren’t working out as planned. And good therapists aren’t necessarily good business owners. It’s just the reality. Remember that no company has a therapy license. You do. You have to protect that.

Money

I saved the longest for last: money. It’s easy to compare job listings and think- this one says $100 an hour and this one says $45 an hour. Obviously the $100 is better. Well…. maybe. Sometimes that’s true. Sometimes, it’s a corporate group practice being kinda shady in how they’re marketing their job listing.

The first thing to know is this: most job sites are pretty plug-and-play. They fill in the boxes as closely as they can, which doesn’t always align with what we do. You have to learn how to interpret different types of therapy job listings, because you’re often comparing apples to oranges. Salaries are pretty straightforward, of course. Some group practices do offer W2 full-time and part-time salaries. The next thing you might see are full-time W2 hourly rates. These are the ones that usually look pretty low. That’s because they are true hourly rates, for 40 hour work weeks (or whatever the FTE is). After that, group practices usually structure wages in one of these ways:

1. pay per session only, which is often a fee split (X% to the group, X% to the therapist). You’ll make more each hour, but get paid for fewer of the hours you actually work. This is the most similar to a solo practice.

2. pay one flat rate for sessions, and a different flat rate for administrative/non-clinical work. The clinical rate will typically be less than a fee split option, because you’re also getting paid for admin work. You might also see a higher flat rate and only get paid for clinical work.

3. a hybrid of the two- fee split for sessions, and a flat admin rate

A fee split means that you might not make the same amount for every session. If you take multiple insurances, the rates will vary. Even if the practice is private pay only, there could be multiple rates available (sliding scale, couples vs. individuals, etc.). This is where the advertised pay rates get really confusing, because practices will often list the whole range.

This is also where some of big third party private practice services, like Headway, Alma, Rula, etc. try to get you really interested in them because their rates look way better. They look better because these are services that support solo practitioners to credential with and bill insurance (they support groups too, but if you’re not the group owner, don’t worry about that). They are advertising the gross rates you will receive from insurance reimbursements - pre-tax AND pre-business expenses. So yes, they’re better up front. They may not be better by the time that money trickles down to your personal paycheck.

Demystifying Real Job Listings

Let’s break down a few real job listings, currently on Indeed. I searched like I was looking for myself: “licensed professional counselor” in the Denver, CO metro area. I filtered for outpatient and private practice openings.

General Things to Look for in Job Listings:

1. Job classification: is this position W2 salary, W2 hourly, or 1099?

2. Expectations: is there a minimum caseload/productivity requirement? What expectations exist outside of providing therapeutic care?

3. Location: is the position in-person, remote, or hybrid? Can that change over time?

4. Benefits and perks: differentiate between employee benefits (i.e. insurance, 401(k), etc.) vs. perks. Companies and group practices often tout standard benefits as luxury perks.

5. Clinical setting: does the practice have a particular specialty? Do they accept clients with a wide variety of needs? Even if you’re joining a third party billing company, do they have any say in what kinds of clients you work with?

Real Listing #1: Private Pay Group Practice

This is a listing for a local group practice that does not take insurance. It’s a 1099 contractor role. That’s a little confusing since both “contractor” and “full time” are listed- my guess is that it’s 1099, but they have enough client referrals to fill up a therapist’s caseload to full-time if they want. It’s a 60/40 split, which is clearly stated in the listing. They provide office space, office and therapy supplies (such as the EHR and telehealth system), administrative/billing support, and a consultation group. They also pay the hourly rate for admin, which is nice.

If I were interested, I’d first make sure my clinical goals align with the practice’s specialties. This practice lists children as the main demographic served. I’d also want to ask about caseload minimums and the “evenings required” part. A lot of groups will want you to work evenings or weekends at least occasionally. If I worked here as an LPC, saw 25 clients a week (a general standard for full-time, although you should definitely check with each job about their expectations), and spent another 10 hours a week on admin time, I’d make $3165.40 a week before taxes. Remember that you probably wouldn’t get PTO or sick time, and you likely don’t get paid for cancellations (potentially for no-shows, but that’s not listed). Your wages are basically like a solo practitioner- you make money if you’re working.

Real Listing #2: Insurance Based Group Practice

This next one is for a group practice that takes insurance. It’s also a 1099 position, and also offers a 60-65% split. However, the rates seem to be noticeably higher, ranging from $105-130 per hour. The listing certainly makes it sound like $105-130 is what the clinician earns. But it’s possible that these are the client-facing rates, which would mean clinicians make $63-84.50.

The range exists because of the varying reimbursements of the insurance payers and the practice’s private pay rate. They also provide office space, and do require clinicians to be in-person the majority of the time just from the listing info. It also mentions that there is a wilderness therapy component, which is a cool opportunity if you love wilderness therapy and definitely something to be aware of if you don’t!

They list the various modalities and populations they focus on, and who they’re interested in hiring. Noting the weekly consultations and in-office emphasis, it sounds like this practice would also offer a collaborative feel. It doesn’t note anything about an admin rate, so maybe they offer a lower rate for that, or maybe you get paid for sessions only.

If I were interested, I would also ask about minimum caseload requirements, and their referral volume/general timeline for building a caseload. I’d also ask about the “opportunities for higher fee split” and what that actually means. In addition, I’d want to clarify the rates, as well as ask about an admin rate. I would guess that if $105-130 is what therapists get, there is no admin rate. If therapists get 60-65% of that, I would want to see an admin rate to help compensate.

Let’s assume $105-130 is what the therapists earn. If I worked here as an LPC, seeing 25 clients a week, averaging $117.50, assuming there is no admin rate, I would make about $2937 a week, but I could make anywhere from $2625-3250. Same rules as above regarding PTO and cancellations.

Real Listing #3: Corporate Group Practice

I blacked out the names of the local listings, but since the corporate ones are often nationwide and advertise constantly, I’m showing the whole thing. This listing is for Brightside, a corporate mental health company that focuses on children and adolescents. Working there as a therapist generally means working in one of their counseling centers, which are located all over the country. So it might feel like a local counseling center some days, but it is definitely Corporate. That means you’ll probably have a lot of admin and billing support (you probably don’t have to think about insurance, billing, or claims at all), but also lot of expectations coming down from who-knows-where. Less autonomy for sure, but more stability in some ways. You show up and do your thing, they take care of the rest.

They are offering a W2 salary. I’m guessing the $50k is for part-time, and the $85k is the high end of the range for full-time. They list the hours, but this is where you need to read between the lines. I would bet money that 15 hours a week is not 15 working hours- it’s probably 15 client hours for part-time (and 20 total working hours), and 30 client hours for full-time (40 total working hours). That’s very much on the high end for productivity requirements, as most corporate mental health companies are.

This position comes with health insurance, 401k, and professional development assistance, which probably means a stipend for CE’s and/or license renewals. Without doing more research, it’s hard to say how good the benefits truly are. But they exist, which is more than a lot of local groups offer.

So, how do you compare $85k to $117 or $90 an hour? You need to get a sense of how those hourly rates translate into your take home pay, and an actual salary. Let’s say the $85k job comes with 2 weeks vacation per year (I have no idea what’s actually included). So $85k is for 50 weeks of work per year. That means the job in Boulder is $146,850 for 50 weeks per year. Sounds way better, right? Yes, but no one is paying your taxes or other expenses. I used this income tax calculator to get a very rough estimate, using a single filing status for someone in Colorado. After taxes, the salary is $104k. How about the Denver job, at $90 an hour? With the same calculations, the yearly salary would be $158k. After taxes, it came out to $112k.

Now, both of the group practice salaries are still inflated. You’re likely going to take more than 2 weeks of vacation/sick time, and that’s all unpaid time. You also need to consider cancellations. Yes, many practices charge for late cancellations and no-shows. But most don’t for cancellations that are made in advance, and unless you or the practice are savvy about booking those slots with a cancellation list, you’re going to have openings here and there. The reported average I usually see is around 10%. So let’s do more math, this time with 4 weeks of time off (48 working weeks), minus an additional 10% total income to compensate for cancellations.

Now, the Denver job’s salary is $98k, and the Boulder job’s salary is $92k. You may have other business expenses to cover as well, since you’re a contractor. Unless you have a partner who covers you under their health insurance, you’re paying for that too. And don’t forget a retirement account. So honestly, the salaries suddenly aren’t that different. However, you’ve got twice as much vacation, a smaller caseload, and are working for a local person instead of a corporation. I’d still choose either of the group practices over the corporate mental health job. But just know that if the corporate mental health jobs are the only ones available in your area, it’s not that you’re missing out on some huge opportunity. Once you really do the math, you see that’s not the case. This is also why some of these jobs intentionally list a high hourly rate, rather than helping you break it down to understand your take-home pay.

Real Listing #4: Solo Practice Partnering with a Third Party

Finally, we have a solo practice option. This one is for Headway, and it’s more an ad for a service than a true job listing. You’re not competing against other candidates. If you meet the qualifications, you’re eligible to join their network. Headway is one of several companies that provide credentialing, billing, and basic EHR services to private practitioners to make the process of working with insurance easier.

So what is the hourly rate? How is this a job listing? Well, what this really means is that Headway’s current contracts in Colorado are offering reimbursement rates between $90-127 per session, presumably. So if you sign up with Headway, as a licensed therapist in Colorado, you’d make somewhere in that range per session, depending on which insurance plans you panel with and which plans your clients have. This is your gross pay as a small business owner, so pre-tax and pre-business expenses. A good rule of thumb when you’re completely on your own is to expect to actually take home around 50-55% of your gross pay if you’re a sole proprietor or an LLC. If you become an S Corp, that’s a whole other thing that deserves its own post.

The difference here is that you could see 25 clients a week, 5 clients a week, or anything in between. Generally, these companies allow for total flexibility over your caseload. They will process what you put into their system.

Let’s do more math. If we took the average again ($108), at a full-time caseload, working 48 weeks a year, with a 10% cancellation rate… you would gross $116k. Now it just depends on your tax status and how well you streamline your expenses to end up with a mostly accurate take-home pay amount.

If you want this kind of support for your private practice, I highly recommend setting up initial consults with several different companies. And I would ask these questions:

1. What insurance plans do you panel therapists with?

2. What are the rates offered for each plan? For which CPT codes?

3. Do you credential therapists in multiple states (if you need this)?

4. Are additional services included (EHR, telehealth platform, referrals, etc.)?

5. What is the membership fee?

6. How are claims processed? How often are therapists paid?

7. How do you handle denied claims?

8. Is there a location restriction built into any of your insurance contracts?

Final Thoughts

Despite how long this post was, it’s really just scratching the surface of what to think about when choosing a group or starting your own practice. But I hope it gave you some things to consider, especially around understanding what you’d actually be getting paid at these jobs, and provided some clarity.

Want to talk more about your individual career path? I’d love to chat. You can reach out for a consultation through my website, Ivory & Pine Counseling.

I don’t keep anything behind a paywall on Substack. If you benefit from my writing and would like to add a one-time tip, it’s never expected but always appreciated. Thanks for reading!

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The tendency I see from a lot of therapists is to approach grief from a symptom perspective. It makes sense why. We may feel like we have to keep it all in a diagnosable box for insurance purposes. We may be struggling with a sense of helplessness, knowing nothing we do in therapy can bring back what the client has lost. We might feel a little more in control of the situation if we can label it. So we try to fix what we can. We try to make it better. And we often try to make sense of it, both with the client and internally as we consider how to move forward. All of those tendencies are understandable, but they can also get us stuck in the weeds and missing the core of what our clients need.

There is one important trend I’ve noticed over time when it comes to grief work. Many of my clients have struggled with a similar issue that often lands in second place behind the grief itself: navigating the judgment of others.

You are judged for grieving too openly.

Then you’re judged for packing it away and seemingly not grieving enough.

You get judged for how long you grieve. First it’s too long, then it’s not long enough.

You get judged for how the kids behave after the worst trauma of their lives.

You get judged for “letting yourself go.”

You are judged for how you spend money.

You are judged for asking for help.

Then you’re judged for no longer asking for help.

You’re judged for grieving about “that” when the loss doesn’t fit into a coffin.

Judged for how you attempt to find joy again.

Judged for smiling, because now you’re not sad enough.

Judged for crying at small things that remind you of the loss.

Judged for talking about your loss when it might make others uncomfortable.

Judged for setting boundaries.

Judged for asking existential and spiritual questions as part of your processing.

Judged for needing therapy.

Judged for moving on.

Judged for not moving on.

Judged for changing, as if anything else was possible.

My PSA is simple: stop judging. And yes, I wish I could say this to all the people in my clients’ lives. But I’m also saying it to my fellow therapists, because it’s easy for us to fall into this pattern too.

In our attempts to fix, to patch, to help clients feel better, we can inadvertently add to the shame, judgment, and stigma that the ways they are grieving are wrong.

We cannot do this.

Feeling misunderstood, unsupported, and judged in the therapeutic context is another wound. Another loss. It’s harm.

If you remember nothing else about this post, remember this:

Slow down.

Don’t judge or make assumptions.

Stay curious.

Your client knows you can’t “fix it.” Stop expecting that of yourself.

And remember that everyone grieves differently. No one has the copyright on how to do it right.

So what should you do instead? Well, I honestly think you can go a long way just with what I just mentioned, a lot of compassion, and basic counseling skills. Your clients likely need your presence and support more than anything else.

And I definitely recommend pursuing continuing education in this area, especially if you can find a training specific to the populations you serve if that’s applicable.

In the meantime, remind yourself that none of us are perfect humans or therapists. Keep showing up and keep growing.

Thanks for reading,

Laura

I’m a licensed therapist, clinical supervisor, Millennial toddler mom, and private practice entrepreneur. Sometimes my posts are practical, clinical, or business oriented. Other times I’m exploring the intersection of being a human and a therapist, especially in 2020s America.

If you’re interested in therapy, EMDR (and soon psychedelic assisted) intensives, clinical supervision, or professional consultation, check out my practice website!

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Interested in quick tools and resources for your therapy practice? Check out my therapist resource shop.

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2025 was a hell of a year. Writing and reflection helped me stay (somewhat) sane, and reading others’ work helped a lot too. These are the posts that my community read the most last year.

My 2025 Year-End Practice Financials: a transparent and honest look at a solo practitioner’s finances, to give anyone considering private practice one example of realistic financials.

Questions to Ask in Clinical Supervision: because “how are your clients?” isn’t enough to provide comprehensive, individualized mentoring.

A Big List of Supervision Topics: literally a list of ideas to bring up in supervision, whether you’re the supervisor or supervisee. Great for those days when the topics aren’t flowing naturally.

Should You Join a Group Practice or Go Solo?: things to consider when therapists are looking at their private practice options.

The Many Nuances of Feedback in Clinical Supervision: a topic that became pretty spicy online, which I know partly stems from an often legitimate mistrust of clinical supervisors in the first place. I hope that explaining my thoughts behind the scenes can help humanize my experiences.

If you didn’t get these in your inbox the first time around, I hope they can be helpful now! As always, thanks for reading.

Laura

I switch my son’s shoes so they’re on the right feet.

I want to crawl into a hole or leave everything behind.

I don’t. I get up after another night of interrupted sleep and cold symptoms that never quite go away.

I sob over my sleeping toddler and think about Palestinian mothers whose babies have been killed.

I fold laundry while we watch Paw Patrol.

I watch the administration begin an attempt to control another sovereign nation with our tax dollars, while we don’t have affordable healthcare or childcare and 6000 veterans take their lives every year and our neighbors are unhoused.

I get my kid dressed so he can play in the snow. I watch him run around like a tiny explorer, just like me in the 90s.

I donate to a food bank.

I fill out a credentialing application.

I feel helpless in therapy sessions when my clients and I see the same things, experience the same things, live the same things. Neither of us can fix any of it.

I write another progress note.

I am horrified at ICE invading daycare centers and dragging away teachers who love our babies as their own every day. Daycare centers just like the one my son goes to.

I pay my estimated taxes for Q4.

My entire nervous system goes on high alert when I see new statements from Evangelical Christian leaders, like the ones I grew up believing, spewing the least Christ-like words I’ve ever heard. Until the next statement tops that one.

I buy my son more clothes, since he’s in the stain-and-destroy phase.

I want to go on strike and refuse to keep giving them my labor.

I refill the juice cup.

I remember that my labor is inextricably tied to the mental health and coping of dozens of other people. I can’t take that away from them. I can’t survive without working.

I unload the dishwasher.

I sob over my sleeping toddler again and think about mothers who have been taken from their children by ICE. Who can’t hug and kiss their babies like I just did.

I give him another kiss, to fix a boo boo.

I want another baby, but I know it’s not even an option unless either society or our financial situation changes drastically overnight.

I get my coffee fix at Dutch Bros.

I don’t think my mind or heart can take any more trauma or pain. It’s an onslaught that never stops - at work, in the world, online, in our communities.

They can, apparently. I keep going. I laugh at reels and TikToks because I don’t know what else to do.

I take an edible because despite my constant fatigue, the anxiety keeps me from falling asleep.

I sing “Open, Shut Them” and “Twinkle Twinkle Little Star” 20 times in a row.

I have nightmares that a school shooter will rampage through my son’s school someday. I’m already terrified to send him and he’s only 2.

I remind my son to look both ways before crossing the street.

I wonder what kind of world, what kind of future, our children will inherit. I deeply hope it’s better than this. I struggle to stay optimistic sometimes, but I really try.

I get dressed for dinner with the girls.

I wake up, take a deep breath, pour my coffee, and do it all again.

I honestly feel quite weird about sharing my income and financial breakdown on the internet. Money is still a taboo topic in many parts of the therapy world. I don’t think we can pinpoint one particular reason, but I have a few guesses.

Most therapists don’t get into this field thinking it will make them rich. We get into the field for deeper reasons- personal, moral, ethical, purposeful reasons. But then, that initial purpose often gets exploited. So many of us were taught from grad school on that we shouldn’t expect to get paid much, and we shouldn’t ask for it. We should focus on the intangible rewards of helping others and to want a sustainable income from that would be to exploit clients. Etc. ad nauseam.

And then we don’t get paid well: in internships (if we get paid at all), during the pre-licensure period of graduating, and often long into our careers. We’re not taught how to advocate for ourselves as a profession. We are shamed and gaslit for wanting reasonable incomes. Insurance companies give us garbage reimbursement rates right next to bullshit lip service about the importance of mental health. All of this just adds to the shame and stigma of openly discussing money amongst therapists.

So yeah. It feels weird to share the details of my income on the internet. But that’s part of why I think it’s important.

You’ll see that my income is nothing spectacular. Not even really that great. I’m not some mindset coach telling you how I made $400k in my first 6 months of coaching with my signature program, and you can learn how to do the same thing if you purchase my program for only $1,999! But that’s another reason why transparency matters.

General Business Model

My practice is registered as a PLLC and I am an S Corp for tax purposes. This means that I am an employee of my business, and am paid a W2 salary every two weeks. My business pays employer taxes, and I pay employee taxes, just like other W2 jobs. My practice is my sole income, and I generally work full-time.

My income is a mix of therapy, clinical supervision, and various consulting projects. I take insurance both for my own therapy clients, as well as for supervisory billing purposes. I do offer other therapy services that are out of pocket, such as EMDR intensives.

Quick Stats

Total practice gross income: about $128,000

My W2 salary as an employee of my business (S Corp tax status): about $62,000, with another $13,000 in distributions outside of my paychecks, similar to bonuses

Federal and state taxes paid so far this year:

• Estimated taxes paid: about $16,400

• Employer taxes my business paid: $4600

• Employee taxes I paid (taken out of my paychecks): $8100

Total business debt: $0. I made personal investments into my business when I first started, but don’t have any rolling debt or loans to pay off related to my practice. I have a business credit card, and generally use it to pay fixed expenses and then pay off the balance each month.

Workload

So how much did I work to earn what I earned?

Total Vacation: about 4 weeks, plus most holidays

I generally worked 4 days a week throughout the year, but often used Fridays as a back-up day if I needed to reschedule clients or needed to fit in an extra meeting. Most of the time, I worked a half day at most on Fridays. I only worked on weekends for EMDR intensives, just a couple times the whole year.

I wasn’t able to look back at my calendar and track sick days very easily. Most of my sick days were because my toddler was sick and had to stay home from daycare, and a few were me being sick separate from him. The majority of the time, I made up those appointments later in the week - accounting for some of the Fridays I worked. I often tag teamed childcare with my husband and still worked partial days when my son was home sick.

I generally have 6 appointments per day x 4 days a week, and then maybe a couple more on Fridays. These were not all therapy appointments. A lot of my work is supervision, and those appointments could also be things like consultations, presenting a training, facilitating a meeting, facilitating group supervision, things like that. But I was generally in front of someone actively engaged in clinical work about 6 hours a day. I often tacked new supervisee or new client consultations onto the beginning of my day, in addition to the typical 6 appointments.

I often did admin work after bedtime, one of my least favorite habits. But the reality is that my schedule just didn’t allow for all the admin time I needed during the work day.

Overall, I worked an average of 4 days per week, and 35-40 hours.

Clinical Work Breakdown

Therapy:

• Insurance reimbursed sessions: ranged from $80-130 per session

• Private pay sessions: my standard rate was $150, with a couple of clients on sliding scale rates or pro bono at some point throughout the year.

• EMDR intensive sessions: ranged from 1 day at $1200 to 3 days at $3000. I did a handful of intensives over the course of the year.

This category is about 35% of my income.

Supervision:

• Individual supervision rate: $125 or $105 per session (I had a bulk discount rate most of the year); in December the rate changed to $120 for everyone

• Group supervision: $80 or $65 per 90 minute group, which changed to $50 in December. I had small groups, and generally made anywhere from $150-220 per group.

• Group contracted supervision: I work with a group practice and provide individual and group supervision. All clinical work was reimbursed at $80/hour.

• Documentation/admin: One practice paid me $50/hr for administrative work, including review of and signing my supervisees’ documentation. Another group paid me 5% of what my supervisees billed. The slowest months were about $500. My biggest months brought in about $2000 from this.

This category is about 60% of my income.

Speaking, Training, and Consultation:

• I charge $130-150 for individual, professional/licensed consultation

• I did occasional trainings for local organizations, which typically brought in several hundred dollars for a 2 hour training.

• I had occasional consultations with non-clinical research firms, bringing in $125-180 per hour.

• I have recently signed on to do some consulting work that looks more like editing content for clinical accuracy, but this just started near the end of the year.

This category is about 5% of my income.

Expenses:

Total business expenses (not including my salary or other distributions): around $8,000

Top expense categories:

• personal health insurance for myself and my family - around $9300

• rent and lease (I only rented an office by the hour, about 1 afternoon per week) - around $2800

• software services (including my EHR, third party credentialing platform, and other software) - around $2700

• accounting fees - around $2400

• advertising and marketing (including marketing, software for marketing, and my website) - around $1100

Debrief

So… what went well this year? What do I plan to change for next year?

Overall, I’m happy with my total income. My goal was $125k and I surpassed that. However, this still left me with a pretty modest take-home pay, and I often still struggled to keep up. My son’s daycare was basically one paycheck every month. I am incredibly thankful to have a partner who also contributed significantly to household expenses, keeping us afloat. But we don’t have a huge “safety net” as he is also self-employed.

I know there are some key areas to reduce expenses in, in order to accommodate things I can’t control. Our health insurance costs are going up significantly next year, and my son will likely start going to daycare/preschool 5 days a week in early 2026, pushing that cost up as well. I hardly contributed anything to my retirement account this year, and want to start doing that more in 2026. We are also just dealing with inflation and uncertainty like everyone else.

I’d say my practice is in a middle phase of development. I have a well established model and income flow. I did not have to worry about getting new clients or finding other ways to make money. If anything, I was overwhelmed with work. But I’m not fully satisfied with where my practice is either, and have many ideas for improving next year. I am in a phase of needing to prioritize the work that is the most rewarding and financially sustainable.

What went well:

1. I feel good about my reimbursement rates and the ease of billing overall. I have to spend very little time on billing and revenue cycle management.

2. I really enjoy supervision and like that this is the majority of my workload. I have gotten to work with and support so many talented clinicians this year, which is its own reward. But I also get to use a different part of my brain during supervision, which has helped protect me from burnout.

What I’d like to do differently in 2026:

1. Streamline expenses: reviewing expenses is always incredibly helpful for me. There were so many small expenses (and some big ones) that I didn’t really need that added up throughout the year. I want to ensure that my expenses are more intentional next year.

2. Prioritize higher paying opportunities: I am re-evaluating what opportunities are most beneficial, and may need to reduce work that pays significantly less than other parts of my workload. Because most of my activities are time-based, I need to maximize my hourly rate in order to increase my overall income.

3. Build in more admin time: I’m so tired of the late night admin work. I know if I focus on higher paying opportunities, that will also allow me to have fewer appointments overall and build in more admin time during the work day.

4. Make space for new income sources: This is closely related to making space for admin work. I have a lot of ideas for things like developing continued education courses and improving my intensive offerings. But I can’t work on those if I’m in 6+ appointments every day.

So there you have it! If you do a similar financial review as a private practitioner, I’d love to hear what resonated with you from my review, what you’ve learned from your own financials, and what you plan to do differently next year. Thanks for reading!