Is your therapist getting paid?

And other questions worth asking.

Hello readers and friends! I hope you’ve spent some time outside this week. If not, do it now!! Reality Test will be taking a two week vacation while I am traveling in Norway floating through fjords or whatever one does there. 

It’s hard to find a good therapist. Word of mouth, referrals, online directories like Psychology Today, ZocDoc, Manhattan Alternative – they all work fine, but obstacles abound. In-network therapists are hard to come by, especially if you’re looking for a specific treatment or specialty. Insurance companies mostly prefer to cover manualized, time-limited, “evidence based” treatments like Cognitive Behavioral Therapy. All this leads to a messy, complicated system where people struggle to find therapists, therapists struggle to find clients, and everyone ends up confused. 

Part of the goal of this newsletter is to make some of the opaque parts of therapy slightly more legible. One of those parts I’ve been asked about by clients and friends is the acronym alphabet you encounter while looking for a therapist. There are a wide variety of licenses, education, experience, and training that therapists might have.

This is a non-comprehensive list of some of the most common credentials you’ll encounter and roughly what they mean (Some of this varies state by state. I put together this list for New York, where I practice and where most of this newsletter’s readers live):

• Clinical psychologist (PsyD/PhD): Doctorate + min. 1 year supervised postdoctoral experience. PsyD more focused on practice; PhD more focused on research.

• Psychiatrist (MD): Medical doctor. Some offer therapy, many focus on medication management. 

• Licensed Clinical Social Worker (LCSW): Master's degree + at least 3 years postgrad experience, exam. Highest level of licensure for a social worker.

  • Licensed Master Social Worker (LMSW): Master’s degree + licensing exam, requires supervision of an LCSW. Often working toward their independent license.

• Licensed Mental Health Counselor (LMHC): Master's degree + at least 2 years supervised postgrad experience, exam. 

• Licensed Marriage and Family Therapist (LMFT): Master's degree + at least 2 years supervised postgrad experience, exam.

  • Pre-licensed/associate: Usually working toward independent licensure as an LMHC or LMFT. This isn’t an official designation, though. Ask. 

• Intern: current grad student, no license. Works under supervision of a licensed professional with oversight from the school. 

After grad school and licensing, therapists can go on and spend months to years and thousands more dollars to be trained and/or certified in some specialized modality. Barrier to entry is HIGH. 

What is my therapist making?

Therapy is prohibitively expensive. You may assume that your therapist is pocketing the entire fee and raking it in. Some are. Often, it’s more complicated than that. (Disclosure: I’m an LMSW, so I’m mostly speaking to my own experience here.)

Rates vary based on location, experience, training, and modality. You’ll pay more in NYC than you will in, like, Albuquerque. 

When you work with an out-of-network therapist who works for someone else, either because they work under supervision or because they work for a group practice or agency, some of the fee you pay likely goes to that individual, and the rest goes back into the business that employs them.

Sometimes if you reach out to an agency or group practice, you may be referred to an intern. This should be made clear to you. That’s a hard ethical line. Unfortunately, I have seen it crossed. That’s why it’s always worthwhile to check licensure. 

Ours is a profession where unpaid internships continue to be the standard. If you work with an intern, it is overwhelmingly likely they are not being paid, a situation that continues to be appalling and shuts out an enormous amount of people from he profession who would be great at it.

Beyond interns, here are some of the different pay structures for therapists who work for other people, whether they are under supervision, work as full-time employees, or work as independent contractors for group practices: 

• Fee-for-service (flat rate): Therapist gets paid a fixed amount per session. I’ve seen this number as low as $25/session (a few dollars more than I make at the wine store where I pick up a shift occasionally mostly for fun). 

• Fee-for-service (percentage split): Therapist makes a percentage of each client’s fee. Usually around 50-60% with the possibility to increase as the caseload does, so therapists are incentivized to take on more clients. 

• Salary: Less common. Often low, often requiring a large caseload.

When you work with an independently licensed therapist running their own private practice, the fee goes to the individual and the costs of running their business. Even when working for a group practice, therapists often are responsible for the cost of their own health insurance and do not receive benefits. 

I’m intentionally not addressing insurance here – it’s its own nightmarishly confusing subject. It’s too weedsy for today, but here's a guide with answers to some of the basic questions. 

Great. So…how do I find a good therapist?

Much has been written about what questions to ask a prospective therapist. Here’s a good starting point. With that in mind, here are some maybe less obvious rules of thumb and things to look out for when looking for a therapist:

• Education/training/licensure level

  • If the therapist works under supervision, consider asking about their supervisor’s treatment philosophy as well. This person will have an impact on how your therapist practices.

  • Don’t discount younger therapists or those working toward licensure! They are often energetic, attentive, and plugged into new developments in research & practice.

  • It’s normal for a therapist to have a robust toolkit of techniques and theories, but if a therapist claims expertise in a long list of specialized interventions, seek additional information. Specialized expertise comes with time and focus. I’ve seen some ethical fuzz in this area.. 

• Rates

  • Familiarize yourself with standard rates in your area. If you are being charged an exorbitant fee to work with an intern or a pre-licensed therapist in an agency or group practice, be skeptical of that business. The therapist is likely not seeing much, if any, of that money. Rates should correspond with experience level, and this may mean that you are giving business to a greedy practice owner. 

  • If you can’t afford the therapist you’ve met with, you can always ask them for a referral to someone who takes your insurance or offers a lower fee. This can be a great way to find a therapist.

  • If you’re meeting with an out of network therapist, think about your budget first. Many therapists offer a sliding scale. Please remember that sliding scale is meant for people who cannot afford therapy otherwise. If you make enough money to go to dinners, or on vacations, or online shop with some regularity, please think twice about asking for a reduced fee. This has a material impact – therapists can only afford so many sliding scale clients, so if you’re just trying to use a sliding scale like an online discount code, understand that’s actively taking a slot away from someone who otherwise cannot afford therapy. 

• A few extra thoughts: 

  • Be wary of anyone who guarantees you any kind of result, ever. 

  • Be cautious with life coaches! Coaching is a largely unregulated field. There are good coaches, but be extra scrupulous when confirming credentials and experience. 

  • If you are working with a particularly sensitive issue, such as trauma, take extra care when choosing your therapist in order to mitigate the risk to your emotional well being. Trauma treatment done improperly can cause real harm.

Trust your intuition – if you feel like you’re getting a sales pitch or a runaround, be attentive to that reaction. 

Most importantly: If you have any questions, hesitations, or doubts, ask. A good therapist should be able to talk you through all of this stuff with empathy and clarity and be honest about anything they don’t know or cannot guarantee. 

Happy therapist shopping! 

Therapy speak backlash gets dark

With the casual return of slurs. Friends…please do not try to reclaim a slur against a group you are not part of. It’s not cute, and you will regret it. There are better ways to be annoying, like being the friend who regularly drags everyone out to see terrible movies in the theater.

Speaking of which…

It (the newsletter) Ends With This

Things from It Ends With Us that, in my professional opinion, I do not recommend doing (**spoilers**):

• Giving an ultimatum to a friend trying to get out of an abusive relationship (“If you take him back, I will never speak to you again”)

• Getting married to someone before discussing topics such as how was your childhood, what’s your relationship with your parents like, etc

• Inviting your abusive husband for a visit to the new home you moved into in order to escape him (while very pregnant)

• Asking for a divorce from your abusive husband while he is HOLDING your newborn baby in the delivery room

• Naming said child after your abusive ex husband’s greatest trauma

• Marrying a man named Ryle

• Expecting anything good to happen in Boston

Ha ha. But really – this movie is terrible. Everyone involved is a villain and I apologize to the powers that be for spending twenty American dollars for a ticket + ten dollars on a Coca Cola (!!) at the Alamo Drafthouse. I’m an abolitionist but…jail to all. 

Do you have thoughts or questions about navigating a therapy consult? Not sure how to interpret something a therapist has said to you? Seen any bad therapy movies lately? Hit me up! And, if you think my approach might be right for you or someone you know, I am taking clients. :)