So, who here likes giant walls of text!?!? If so, have I got a blog for you.
I work as a mental health therapist in Washington State. One of the coolest benefits of working this job is learning all about different cultures, all from my office. But one of the weird side effects of that benefit is that I also learn about my own culture as well, but from a very different lens. Recently, a client who grew up in Russia pointed out that Americans seem to be both obsessed with money but also reluctant to talk about money with anyone else. Obviously, this may be in part due to the state I live in, Washington, as I can’t say for certain if other states are as tight lipped about their income. But, yeah, Washingtonians certainly do this.
But it’s not just money. I didn’t work a day as a therapist, or directly observe therapy work, until the last year of my Master’s. I didn’t know for certain if I would like to work as a therapist until I was all the way in debt and too far into my education to easily change paths. I also didn’t have a clear indication of what the pay would be like. And I don’t mean a money amount, but rather if the pay would be a livable wage or not.
So, I thought it would be interesting and possibly beneficial to go through my career process, from graduating with a Master’s to where I am now, working in private practice. I’m not going to talk about the therapy process, but more what it’s like to do the job.
What Happens After College
I ended up getting a Master’s in Clinical Psychology (6 years post high school) and stopping there. You can stop after getting a Bachelors in Psychology (4 years) but the job market for a BA in Psychology isn’t too great. With a Master’s, I can diagnose mental health diagnoses, perform therapy (individual, group, couples, family), supervise other therapists, and so on. A Doctorate in Psychology (7 years+) opens up the possibility to perform more complex assessments, like personality and IQ tests, work as a court psychologist, and if you get your medical degree as well you can become a Psychiatrist and prescribe psychotropic medications. Doctors also perform psychological research. All I wanted was to perform therapy, so a Master’s was fine with me. My therapy internship, which occurred at what would be my first therapy job, sealed the deal for me. I was good at therapy and I enjoyed doing it. It was fun learning about people, seeing them grow and improve, and it was challenging and fulfilling.
When you graduate college with your Master’s in Psych, you apply for a license with the department of health to work in your field. That license is considered an ‘associate’ license, meaning that it allows you to perform your job but with limitations. I left college with an LMHC-A. Meaning, I was a ‘licensed mental health counselor – associate.’ I could work, but I couldn’t get on the boards of most insurance companies (meaning they wouldn’t recognize me and pay me for services rendered). At that point, I could have started a private practice, meaning I work on my own or with a group of therapists, but my clientele would have been small. Thus, most people out of school join a Community Health Clinic (CHC).
CHC are usually non-profit organizations that offer all types of healthcare services. The clinic I worked for offered medical, dental, substance abuse, and mental health services. In my field, the general impression of a CHC is that you go there to ‘put in your time.’ For a while, that meant working there until you could drop the ‘a’ from your license, get on insurance boards, and make it on your own in private practice. For reference, to ‘drop the a’ you need to meet certain criteria stipulated by your state’s department of health. For me that meant essentially working two years under a supervisor who was fully licensed, receiving a set number of supervision hours, attaining a set number of therapy session hours, earning a set number of continuing education credits, and passing a test. The ‘putting in your time’ changed a bit over the last few decades in that government programs had been created that would pay out a set amount of money for those that worked with underrepresented people, which is essentially 80% of the CHC clientele, but as of the last few years it has been harder and harder to get access to those funds. I think I remember hearing that 2-5% of those that applied per year received the payout. And doing so required that you worked for the CHC for two years after earning your full license, which meant working at least 4 years at a CHC before moving on to private practice.
My Job at the Community Clinic
For the first two years at the CHC, I worked in their ‘Intensive Outpatient Program.’ This was probably the hardest job I’d ever worked. The work involved seeing clients who were considered high risk for one reason or another. It could be that they are a risk to themselves or others, are homeless, using drugs, regular users of the hospital, are in and out of jail/prison. The job then of the IOP therapist is to mitigate risk and bring the client back up to a level of stability that would allow them to see an outpatient therapist in the clinic. I would see these clients two-four times per week somewhere in the community. Meaning their homes, a library, anywhere. Working with the clients was usually pretty pleasant. The stress came mostly from the lack of resources. There was just more demand than there were resources. There was too much homelessness and not enough homes, too much unemployment and not enough jobs, and on and on it went. Too often I felt in a position where I had to spin a ‘I can’t help you with what you are asking for’ into something hopeful. It was a pretty draining job.
After the two years, I spent three years in their outpatient program as a therapist and, for a bit, as a clinical supervisor. Just to note, I never got that government payout. Anyway, the therapy work in and of itself was easier, but the new issue was the quantity of clients. We had around 6 therapists working at the clinic, but every Tuesday and Thursday, for four hours per day, we were all on call to do therapy assessments and, if they needed it, offer them therapy services. Which, in theory, is a great thing. That means more people can get help. The bad thing is that most of our client lists had 70-80 active clients on it, with most actively engaged in therapy services. Which meant most of us couldn’t keep up with paperwork, meaning our client charts were out of date and we couldn’t keep up to demands for case management work, like sending letters to court and whatnot, and had a hard time keeping track of who our clients even were. I remember one time seeing a client, who I had seen 4-5 times prior, and taking nearly the entire hour-long session before I remembered what their diagnosis was. So, then, work as an OP therapist at the CHC was a constant state of playing catchup.
In terms of the actual pay, whether it’s livable or not depends on your circumstance. I worked for a CHC that had a union. As soon, I started at a base salary that would go up 2% every year for ‘cost of living’ and 2% as I moved up each ‘step’ in the union pay grade ladder, which would cap out after about 7 years of working. Meaning, at my eighth year the pay increase would be 2% annually rather than 4%. At base, as a single man who had student loans, I made enough to live by myself, but just barely. If I had roommates, it would have been easier, but living by yourself is pretty great. But I was living paycheck to paycheck.
CHC Politics-The Clinic
That ‘constant state of catchup’ wasn’t just a mental health thing. Every part of the CHC, from medical, dental, substance use, and mental health all were behind because we were all overwhelmed by the number of clients we had. We were all behind on our paperwork. What’s more, the state government that oversaw the CHC called for audits nearly every month. An audit for the mental health division of a CHC means that a set number of client charts are pulled, at random, and poured over by an auditor to see if we are accurately documenting all of our services, outreach, and so on to the standards of the state, who was paying for the services for our clients (via Medicaid). In an extreme scenario, they may ask for their money back because we had committed fraud, mistreated a client, etc. Most often, though, the result was that the therapist would need to find time to fix the errors and resubmit the charts. Because we had so many clients and so little time, none of our charts were up to standard. And because the audits were every month, we barely had time to implement changes. The state was too big to adjust expectations and put the pressure on the CHCs to fix the errors as we had done before despite the changing environment. The CHC I worked for saw the errors as a problem caused and should be fixed by the therapists. Alternatives to fixing the problem, like hiring a case manager, hiring a separate person just to organize the charts and assist the therapists, negotiating with the state, implementing systemic changes with our paperwork system, etc. All were shot down. As the CHC saw it, problems with work were a problem due to employee. This ‘paperwork is the therapists’ problem’ generalized to other issues as well. No shows. Cancelations. Lack of coordination with other agencies. Which, if all else were equal and the therapists not overworked, those are the therapists’ problems. But things weren’t equal and the failing of the staff is at least in part due to the organization that oversees them.
Due to all that pressure on the therapists to fix problems at the clinic, and because they were overworked with no sign of change on the horizon, cynicism was common in the clinic. Unfortunately, that cynicism was often directed fruitlessly and rudely. It was directed at the clinic’s management, at the support staff, at each other, and worst of all at clients. From my own experience, I did at times engage with the bitch-fests but eventually I stopped, instead deciding to disengage from the clinic and most of my colleagues altogether. I didn’t like that the cynicism bleed over to the clients, who didn’t deserve to be scapegoated when they were simply asking for help. I also didn’t want to attack my colleagues and I found no point in criticizing the clinic when systemic problems seemed well set in place. But my distancing made me appear a bit cold to my colleagues. But I’d rather appear cold to my colleagues than disrespectful to my clients. You can’t win them all, right?
Private practice is a different beast altogether. The short version is that I’m much happier in private practice. The long version is that the growing pains in private practice are immense. So, I left the CHC and joined a group practice with my friend and former manager. She hired me on as an hourly employee with a W-2. What this means to me is that I don’t have to pay self-employment taxes. I work for a business, rather than as an independent contractor. The biggest benefit to me, then, was that I got paid even if the insurance companies didn’t pay us. Which they didn’t, for a long time, because insurance companies are huge and take a long time to pay anyone, let alone someone who is new to their system. Even now, some insurance companies don’t pay us for 3-4 months after the time of service. But, because I was new, some of those payments took 6-9 months. It has only been over the last 9 months, of the two and a half years I’ve been in private practice, that I’ve been paid consistently by insurance companies. Which means my colleague had to float the company all that time. And, if I were on my own, I would have made very little money.
All that said, now that things are running smoothly, the work is much less stressful. The face to face with clients is the same, except now I have 40-50 clients rather than 70-80, meaning I know all about them now. The paperwork is streamlined and much more doable with fewer clients, I have one audit a year rather than one per month and I’m always in the clear. It’s just a better experience overall. Financially as well, now, anyway. I’m not paycheck to paycheck. It’s very nice.
I love being a therapist, but I think newcomers to the field should be made aware of what it’s like coming up in the field. The burnout rate for new therapists is far too high, especially given the need for good therapists. I think the process from graduation to feeling settled in the career should and can be improved, but it’s a much bigger topic than this blog. What I can say is that I feel the work was worth it, even if the work itself was harder than it should have been. Because, now, I’m quite happy in the position I find myself today.