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An Open Letter to My Students VI: C.R.E.A.M, Get the Money

I remember my time doing in-home therapy. One family in particular sticks out.

Grandma was telling me about punishing her grandson after he came home, again, with frogs in his pockets when my anxiety started howling. By this point I was seasoned enough to know that when my anxiety started baying like a bloodhound, if I could listen instead of freaking out, he would let me know something important was happening. Something about how she treated her grandson was different than how she treated her granddaughter.

“I’m sorry,” I paused her. “I’m a little confused. Let me ask a question. Do you ever have any men in the house? Like a boyfriend or something?”

“What do you mean do I have a boyfriend? That has nothing to do with my grandson,” Grandma shot back.

“Well I’m wondering who his models are. How is he learning to become a man?”

At my car a moment later I tried to recoup. I’d been kicked out so fast that everything was a blur. Should I try to get back in? What would all those master therapists I read about in books do? What clever paradoxical scheme would they cook up? And why was I thrown out anyway? I thought I’d asked that question as politely as I could. My heart was still pounding when one of grandma’s friends caught me as I stood inside my car door. “You were right on. You didn’t hear it from me, but she treats that boy like sh*t compared to that girl. And her boyfriend, well he treats her like sh*t. So she passes it on. But she don’t wanna listen to nobody.”

Back at the office my supervisor asked me what had happened. I figured grandmother would be calling her.

“So I’ll discharge them I guess,” I said after catching my supervisor up.

“No fill out a transfer form. We’ll have to give them to someone else. Maybe a female.”

In the doorway I was confused again. “But grandma doesn’t want therapy.” This family had devoured and spit out therapist after therapist for the past three years. Why were we giving them another therapist?

“The referral source is one of our major referral sources. They’re still requesting services.”

The air between me and my supervisor bristled.

Hopefully you’re not as naive as I was and you’ll catch on faster than I did. As a young therapist I knew our first mandate was to help our clients. I did not understand that the first mandate of any organization is to survive, and because of this, money, the life blood of organizations, runs everything. So the first mandates of a therapist and of an organization are often at odds. New therapists are particularly vulnerable for two reasons.

First, you need hours to complete your licensure process. This means you have a need that agencies will use for their monetary gain. They will push you to provide therapy services that you can’t say no to because you need the hours. These services won’t even have to be unethical, just miserable. One of my best friends has a caseload of over 100 patients. He wants clients not to show, because the only way he can finish his paperwork and go home at a reasonable hour is if people don’t show up. Agencies aren’t incentivized to change because there is always another unlicensed therapist who will do the job in order to get the hours.

Second, most new therapists will end up working for agencies which bill insurance, or as it’s called in the field “third party payers”. This is a problem because you’re pushed to cater treatment to whomever pays the bills. I’d bet that most of you will be working with the worst insurance system of all — MEDICAID.

Medicaid does not want to pay for services. I don’t know why. I think it’s because if they paid for everything people needed they would go broke. I think that’s why, but I don’t know. The problem with Medicaid is that the reimbursement processes are *coughintentionallycough* cumbersome and the rates are low. This makes it a pain to help poor people.

Private insurance is a little better but often, whether Medicaid or private, insurances only reimburse for certain DSM/ICD codes. Also, insurance often only reimburses for certain treatments, usually ones labeled evidence based treatments (EBT). Also, it’s not uncommon to only be reimbursed for a certain number of sessions. This means insurance dictates how you diagnose, what treatment you use, and length of treatment, because if you don’t do it their way you don’t get paid. This is a problem for all the same reasons that you can’t learn therapy from a book or a blog- it assumes insurance companies or EBTs have a better understanding of the context than you.

So as a new therapist you are limited in the agencies you work for because you need the hours, and agencies are limited by what kind of care they can give because of what insurance will reimburse. But there’s another big player in treatment — referral sources. Which makes sense. Agencies can’t survive without clients and clients come from referral sources. However, this leaves you as a therapist pushing to keep your clients engaged, instead of them working in therapy from their own motivation. Whenever external motivation is the main motivation you’re going to have problems.

What are you to do? I’ve heard others say that all you need is faith. Do good work and the rest will work itself out. I do not believe this. You must be as innocent as doves and a shrewd as vipers. So please make sure your paperwork is well done. Satisfy the bureaucracy. Make sure you’re following the fundamentals and do good therapy. Make sure you take care of the basics even if you don’t love your job. Then, once the basics are taken care of, look to diversify.

The financial power of being a therapist comes from the fact that people don’t come and bare their secrets and shame to an agency, they come because of the relationship they’ve build with the counselor. As strange as it sounds people come to therapy because they want YOU, YOUR name, YOUR brand.

This is NOT what I wanted to hear as a young therapist. When I first became a therapist I pictured myself as a young Idris Elba who sat and had deep conversations with people. In therapy programs we often promote those jobs as standard, but they actually are really hard to get. I’ve had to learn that therapists do well when they realize that the profession is one for entrepreneurs.

You’ll be best served if you spend your time as a new unlicensed therapist building your brand. You can do this by any number of ways, but the main idea is to use your current job as a platform for your brand. Ask about opportunities to speak, organize trainings, volunteer in community events, or anything related to your field that isn’t direct care. It’s also important to have income from outside of direct care for two reasons.

First, most therapists I know deal with burnout by taking promotions out of direct care into management. However, because most promotions take you out of direct care everyone clamors for these positions, which by definition are limited.

Second, and to bring it full circle, the best reason is if you have income outside of direct care it’s easier to focus on your clients’ needs instead of focusing on trying to survive a system focused on money.

P.S. I think it’s useful to say that after you get licensed go ahead and get paneled with the top insurance providers in your area. This process can take a few months, but it’s better to get on with an insurance provider when you don’t need it then to want to make the shift later and have to wait three months before you can do anything.

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