What it takes to be a therapist
There has been so much discourse lately about the behind the scenes struggles of being a licensed mental health practitioner (Counselor, social worker, psychologist). Maybe because I live over in that part of the internet I am seeing it more, but I am seeing it a lot. There are differing policies and requirements for becoming a fully licensed therapist depending on the type of license and your state; but the one thing that is generally universal amongst all of us, regardless of degree and license, is this…we are not respected by insurance companies. After reading this, you might have a better understanding of why many practicing therapists do not take insurance.
Who are Therapists?
People who study and become licensed in counseling, social work, and psychology might refer to themselves as therapists. It is an umbrella term used to describe the clinical practice of providing mental health support. Licensure requirements vary for each of the disciplines and by state. Getting fully licensed to provide direct services usually requires:
The completion of a masters degree (or doctorate) which includes a several hundred hour internship (usually unpaid)
Passing a licensure exam
Several thousand hours of clinical work - post the completion of a masters degree - under the supervision of a fully licensed supervisor
Money. So much money. Money for the degree, money for the exam, money for the application to get provisional licensure, money for supervision (if it isn’t included with their job), then money to get full licensure. Then money to keep renewing their license yearly or biannually (this is state dependent), money for liability insurance, money for continuing education that is required to keep the license. It is ever ending.
I won’t go into the differences in counseling, social work, and psychology degrees here. But here are some links to helpful information.
American Counseling Association
National Board for Certified Counselors
What Full Licensure Means
Usually upon graduation from a graduate program you take an exam to become provisionally licensed. This means that you can start earning your hours toward full licensure under the supervision of a fully licensed clinician. Once you earn the hours you can apply for full licensure. Once the application is approved (and paid for) then you can choose to open your own practice. You can also get credentialed with insurance panels, so that you can serve clients who want to use insurance to pay for their therapy. Some insurance panels and some states allow provisionally licensed clinicians to accept insurance under supervision. There are just so many rules and regulations it is difficult to navigate. Using myself as an example:
I live in NJ. After I earned my masters degree and passed the NCE licensing exam I became an LAC - Licensed Associate Counselor. After earning 4500 supervised hours I submitted an application for full licensure and was given my LPC - Licensed Professional Counselor - credential. In other states the license might be an LMHC, LPCC - there are a lot of acronyms for licensure!
I have a doctorate degree, but I didn’t need that to get licensed as a counselor. Psychologists usually need a PsyD or PhD to get their clinical license.
Salary/Pay Issues in Mental Health
New provisionally licensed clinicians are often paid very little. They get taken advantage of by the people who hire them. They might get paid per session or get a very low salary (like below livable wage) because they are not fully licensed. The thing about getting paid per session is that it makes salary unpredictable and it also leads to overbooked and burnt out therapists. If you get paid per session you have to plan your schedule around possible/probable cancellations. People will often schedule themselves for 30 sessions a week, which is A LOT, and hope that they get 25.
There is a push for salary transparency right now which I LOVE. You will see therapists sharing/posting their monthly income on social media. This is supposed to help other therapists or future therapists see what is possible. Most of the sharing I have seen comes from people who would also be considered “creators” who also have additional income streams. So the numbers could be misleading. It is a good start to an important discussion though.
Insurance companies
Insurance is what makes healthcare accessible for the majority of clients/patients Clinicians want to be accessible. However, insurance companies make it difficult to provide quality services. We have to jump through hoops to get "credentialed" (meaning we are listed as “in-network” with a provider). It can take months or years to get approved, and they can even decide to deny you if they think that your location is “oversaturated” with mental health professionals.
Insurance companies:
Require a formal diagnosis that they deem worthy of treatment. This is a complex issue and one that drives mental health clinicians UP A WALL!
Insist that you keep documentation of evidenced based measurable interventions.
Pay based on
The discipline of degree (social work, psychologist, counselor) meaning that some insurance companies pay clinical social workers at higher rates than licensed counselors.
Level of degree (i.e. MA vs PhD - but if you have a PhD in Counseling they do not increase your rates - at least not in my experience)
The number of minutes in a session. The simple breakdown is usually a 45 minute session vs a 60 minute session. But it is actually 38-52 minutes vs 53+ minutes.
Can ask for your notes on a client and determine that they do not find your interventions worthy of reimbursement - after they have already paid you. This is sometimes referred to as a ”clawback” because they take back money you have already received. The real issue is that these determinations are often (or maybe always) not made by clinical professionals.
Can tell you that you have had too many 52+ minute sessions and start to ask for money back or refuse to reimburse at that rate anymore.
Some insurance companies do not pay quickly. If you are an insurance based private practice, you cannot plan around receiving the same amount of money on a weekly or bi-weekly basis. The processing of every insurance claim is dependent on the insurance company, method of submission, and the hope that there are no technical issues.
Running a Private Practice
Running a private practice is a lot of work. It takes a lot of planning and you need to be somewhat business minded. I will save this discussion for another post. But running a private practice really does require that you think through a lot of things like fees, insurance, cost of operation (yes even if you are virtual and not renting a physical space), etc. The flexibility to make your own schedule is great, but there are so many important things that need to be taken care of to run a successful, ethical, balanced practice.
Current Concerns for Practitioners
There are several issues plaguing the clinical community right now. It seems that mental health Venture Capital Companies (Alma, headway, betterhelp) are taking over and while at the start they had a lot of pros, we are starting to see the results of what feels like a long con happening. Insurance reimbursement rates are changing, AI is being pushed, and costs are increasing.
Here are links to some of the issues clinicians are facing right now:
Alma Aetna Issue I plan on sharing more about my experience and feelings about Alma in a future post. The issue affects me personally.
Bluecross Blueshield cutting back on reimbursing provisionally licensed professionals
If you are thinking about becoming a licensed therapist (with whatever license/degree) consider everything you have read here. We do important work but getting to do the work takes a lot of preparation and it can be complicated and frustrating once you’re in the field. I am a full-time professor of counseling. I have discussions with masters degree students often about the ins and outs of being a clinician and running a private practice.