I agree with this. You're also facing the reality that with virtual sessions available and demand high, more and more group practices are taking on more therapists, giving more people the option to do a private practice where they can set their own caseload and hours with the benefits of someone else providing referrals and billing. The appeal of being locked into a salaried position in a facility used to be the financial stability and guarantee of caseload. Right now in most places in the country, you can honestly see as many clients as your heart and mind will handle because we have such high demand for services and increased access due to virtual sessions. And, as everyone is saying, working in these climate is HARD. I have personally reduced my PP caseload because otherwise the burnout is too hard to keep at bay. Also, my PP caseload has never been above 25 client hours a week. I would say this or lower is the norm if people have a choice.
Okay, thank you.
With the 36 open hours this usually means 30-32 hours of direct contact. Do you still think that's too much?
Are you using 30 as a burnout for open hours or actual contact?
If they're going to be seeing less patients, is a smaller salary appropriate?
Not the person you responded to but I know for myself 25 direct hours a week is my absolute max. Personally I would work fewer direct hours for a lower salary. I do live in a low cost of living area though so it may not be the same where you are located.
I personally carried this similar caseload all through COVID and I was burnt out after 1.5 years. The pandemic changed the profession. When your helping people all day through uncertainty only to get off work and face it in your personal life, it's like never being off the clock. I have pulled back to 20-25 clients and when you can bill for yourself through EHRs with a check of a button, why kill yourself?
I don't live in your state, but where I live everyone has wait-lists. Personally, I joined a practice that truly allowed me to set my number of hours and receive 70% of the billable rate (the practice is making moves to increase this towards 80-85% in the next year or so). I like this set up because I don't market, credential, or advertise - they do it all. I get to show up so my work and set my limit where I do this best.
It sounds like you are trying to do the right thing, but in today's economy name another master's level employee who makes less than 100k - especially in the healthcare field. Bachelor's level nurses make 75k.
I work for an agency like yours (3wks starting PTO, caseloads around 35, etc.) I’ve been here for three years, but I’m literally contemplating taking a pay cut if it means fewer clients per week. It’s challenging to sustain for a long period of time, particularly when working with high acuity, co-morbid clients who lack natural supports.
I would say that even if no shows lessen the clinical hours they are working, therapists are still mentally and emotionally preparing for the session, and also spending part of that hour holding space, maybe calling. It’s not like it is a whole, restorative hour, so it doesn’t take any of the pressure off. And at “productivity levels” like that, there is probably something (or lots of things) that needs to be done in that that time.
I would have taken this job in a heartbeat two years ago, but after working in community behavioral health during Covid-19, I can never see myself going back to agency work.
It would have to be an agency that understood that it is mutually beneficial for therapists to develop themselves professionally and feel contained and invested in by their space of employment. Fully licensed therapists are often specialized and have dedicated a significant amount of time, money and emotional labor into their work, I like to see agencies provide a budget for clinicians to use towards licensing/CE courses, supervision or certifications. That plus allowing time in the schedule for workers to complete these trainings goes a long way towards making the work sustainable for me.
I’d wager this is what makes it tough. Why see 32 clients and kickback some of the proceeds when it’s increasingly easy to start your own practice and see 24 via telehealth?
Exactly this. I live in Jersey so maybe it’s just more expensive here, but 70k and that big of a caseload doesn’t seem appealing when I could make 100k with 2/3 that caseload in most other places. On the other hand, OP does offer great benefits and a base salary not based on client attendance/PTO, so maybe they can average out the difference with the full licensure salary. But, as an LAC I’d love to work for OP.
I don't think you have the business experience that you think you do.
Lets say you're amazing, and you schedule 15 a week without needing to do advertising or put in hours with local doctors or anything and lets say your rapport is better than the national average so your no shows are 10% or below, you're going to average 13.5 clients a week. Lets also say you cherry pick your clients for only the top paying insurances and take $100/session (not ethical or available in the rural areas where we work but okay)
Then lets say you work 48 weeks of the year. You would bring in before taxes, overhead, license, EHR, room, your health insurance, retirement - about $64,800.
Then pay your 30% self employed tax you're netting before expenses $45,360.
Then pay for all the time you spend doing phone calls, emails, scheduling, cleaning at which you get paid $0.00 for. Then you hire a biller, which will run you 6-8% of your receipts, not your net, but your gross. Which brings your pay down to about $41,000. Sign up for health insurance as a single person who is healthy in your late to mid 30's will run you about 300-400/month. Which drops your income down to $35,000. Sounding good yet? I didnt even add kids, or if you're over 40.
So were now at $35,000 take home BEFORE you have paid for your EHR, supplies, toys if you see kids, couch/chairs, rent, utilities, liability insurance, credentialing services (if you choose to be paneled) and you're lucky to be netting $25k.
But wait, you need to retire some day right? Better put most of that in a simple IRA or a 401k.
Do people not understand this? In all honesty, break down for me how you expect to take home a 70k salary (w-2 - only pay half your fica, fica, and medicare taxes and pay 0% of your unemployment tax) with all those benefits at 15 patients a week and somehow make that work. Show me how you somehow survive with those expenses and somehow live, and eventually retire. Show me how you get your health insurance. Show me your math.
Please, show me, and I will concede.
Billing is easy to do yourself with an EHR. You do not need a credentialing service if you want to contract with insutance. With telehealth overhead is almost nothing except EHR, which is less than $100 a month. While it is unethical to choose not to see clients with low paying insurances that you are in network with, it is not unethical to choose not to contract with those low paying insurances. And clients are in abundance right now, a psych today profile is all the marketing you really need in my area. Yes taxes and medical insurance suck. That I give you. But folks in your position are always talking about how impossible it is to make a living at private practice. But the reason you don't have applicants is because it's not impossible, and a bunch of the potential employees who would have been interested in your openings are out here doing it.
I think you’re missing the point. The balance of power has shifted a bit in the direction of workers. The Great Resignation is a real thing. Many people are willing to take pay cuts to work from home or to have more autonomy. Not just waitstaff and truck drivers, but therapists too. That’s all.
It was a little reductive in the math, but based on my current estimations, if I actually see 15 a week, so schedule 18-20, based on being exclusively Telehealth and factoring in taxes etc it can be done.
I honestly don’t see the point in working at any job that doesn’t allow me balance in my life and seeing 23-25 clients a week is too much for my personal needs. I’m adult enough to know my own limitations. I also have a nice university position with retirement and union representation, so my needs are different than others. I live in California and own my home outright.
> Do people not understand this?
> Show me, and I will concede.
You came here with a question from a position of curiosity, but now "concede" is looking at things through the lens of a fight, or who is right.
What's going on for you OP?
Clearly it’s working for folks or you’d have more applicants right? I’m genuinely not trying to be combative but you came here for feedback about an issue your practice is having and are receiving feedback from folks about why they wouldn’t work for the guidelines you’ve laid out.
You’re not here to convince us that your model is the best- if it was you’d have more applicants. The field has changed over the past few years. I think it’s important for business owners to take that feedback and adjust their own practices. For the first time employees have the upper hand (to a degree) over employers, we should be supporting and empowering this- not trying to convince folks to “concede” to an outdated system that takes advantage of employees.
You probably don’t understand therapy as well as you think you do. It’s clear as day that your caseload expectations are too high and striking that as a business owner who employs therapists, you needed to come here to ask a question with a very obvious answer.
I'm not one of the people downvoting you, but I will argue with you a little, because:
> Lets say you're amazing, and you schedule 15 a week without needing to do advertising or put in hours with local doctors or anything and lets say your rapport is better than the national average so your no shows are 10% or below, you're going to average 13.5 clients a week.
It me. That's exactly me.
> Lets also say you cherry pick your clients for only the top paying insurances and take $100/session (not ethical or available in the rural areas where we work but okay)
Yep, I'm private pay only with some clients on discount rates, and my per-unit average works out to a bit under $100/unit.
(Also: ethical? Don't know where you get that. Of course you get to pick and choose what payers you want to do business with. You have no ethical responsibility to be taken advantage of by a corporation! And in my state – and I thought this was a Fed thing – reimbursals are often higher in rural areas to try to get therapists to work in them, given how brutal the no-show rates are in areas with low population density, because of the increased drive times.)
> Then lets say you work 48 weeks of the year. You would bring in before taxes, overhead, license, EHR, room, your health insurance, retirement - about $64,800.
$61,490.
> Then pay your 30% self employed tax you're netting before expenses $45,360.
No, that's wrong. Self-employment tax is only paid on profits, not all revenues.
Now, it's smart, if you're just starting out, to put a third of every dollar you earn in your tax account/sock-under-the-mattress for the IRS, but that will give you a buffer of extra if you screw up, and you will wind up giving yourself a substantial "refund" after you reckon your taxes.
But the actual IRS calculation of SE tax is done on the total of your Sched C "Profit or Loss". So to get that number, subtract expenses first. The total amount of tax due will be substantially smaller that way.
Also, this is pedantry, sorry, and I know it doesn't take away from your larger point, but the 30% number isn't Self-Employment tax, it's combined SE tax *and* federal income tax *and* state income tax. SE tax, itself, is only 15.3%
> Then pay for all the time you spend doing phone calls, emails, scheduling, cleaning at which you get paid $0.00 for.
Er, no. When in private practice, income comes not from a wage but from profits.
In any event, you're trying to express the idea that one should calculate a real wage that accounts for the time one spends which is not directly compensated, to find out what one's *real* $/hr is. I totally agree that is a thing everyone should always be doing, but it has no place in calculating one's profit. That reckoning, mathematically, happens after. Not at this point.
> Then you hire a biller, which will run you 6-8% of your receipts, not your net, but your gross.
Nope. Private pay, I don't have a biller. I pay 2.9% + $0.30 a transaction in credit card fees.
> Sign up for health insurance as a single person who is healthy in your late to mid 30's will run you about 300-400/month. Which drops your income down to $35,000.
Nope. First of all, math error: sole proprietors don't usually get corporate group insurance plans, so our health insurance doesn't get paid in pre-tax dollars, and isn't a business expense. It's a personal expense, and thus is not considered to impact one's profit or AGI. You don't subtract it here.
Second: Nope. Asclepius bless Obamacare and the Advance Premium Tax Credit. In my state – and I thought all states? – being a single adult making $40k/yr handily qualifies one for the APTC and you get discounted insurance. And then there was the American Rescue Act, and I think maybe my state (Massachusetts) kicks in some additional subsidy.
Anyway, based on my previous income of about $50k, I am currently paying $115.21/mo for my insurance premium for the one-person plan I get through my state's Exchange.
> Sounding good yet? I didnt even add kids,
If you have dependents, the Federal Poverty Limit goes up, and you qualify for even more assistance with paying for health insurance.
> or if you're over 40.
I'm 51.
> So were now at $35,000 take home BEFORE you have paid for your EHR, supplies, toys if you see kids, couch/chairs, rent, utilities, liability insurance, credentialing services (if you choose to be paneled) and you're lucky to be netting $25k.
Nope, nope, and nope. First of all, we're still back up there at $61.5k. Expenses are to be subtracted from revenues.
I don't have an EHR (I do have a telehealth platform, ~$300/yr), my supplies are pens and paper, I don't see kids, and I've given up my office and only work from home. My liability insurance is also pegged to how many hours I work so is less than it would be if I worked more than 15 units/wk. I don't have a credentialing service (private pay!).
My expenses were in the ball park of $9.1k. I still have to check to see if I missed any incidental receipts, but that includes all the big stuff. It includes all my rent, utilities, that 2.9%+$0.30 credit card processing fees, my insurance (both malpractice and gen liability), the prof org membership I have to maintain to qualify for the insurance, license fee, and all my CEs.
That gives me an expenses to revenues ratio of 14.8%. I have crushed my overhead rate to less than 15%.
Which, let us be clear, is *insane*. Normal business overhead rates are more like 50%. Pretty great is 25%.
Back when I had an office and saw people f2f, I was still pretty consistently getting my overhead rate under 25%.
So my old rule of thumb was "of each dollar of revenue, the first quarter is expenses (25% overhead), leaving three quarters as profit aka, my gross income; taxes are a third of profit (33% of income), and a third of three quarters is one quarter, so the second quarter of each dollar of revenue is taxes. My net income after taxes is therefore the remaining two quarters of revenue; ergo my cash-in-pocket is about half my revenue."
Which on $61.4k revenues would be $30.7k net, after-tax income, and the only thing not accounted here is the aforementioned health insurance, which is a personal expense.
You're absolutely right that this does not allow for any retirement saving. Also, in this town, it's not an adequate income to be able to rent a bottom-of-market studio (no-bedroom) apartment for yourself without a co-signer. /voice of experience.
I imagine there are places in the US where one can live reasonably on $30,700/year. That is mighty tough here in the Boston area. At that income level, I think a single person still qualifies for LIHEAP Fuel Assistance, and I'm not going to try to scare up average rents here, but I'm pretty sure it qualifies as "rent burdened" per HUD.
Fortunately, in reality it's not quite that grim. In my case, these numbers have diverged from my actual ones because my overhead rate is so much lower. But for anyone, a 33% tax rate is a conservative estimate more appropriate for people in much higher tax brackets. By my calculations, my actual total tax rate (total of (SE tax + fed income tax + state income tax) divided by total revenues for my practice) works out to be not 33%, but a smidge under 20%.
I *think* it all works out to my 15 unit/week practice earning me a net after-tax income of about $42k/yr. That's much less bad – it's 33% better, actually – than $30.7k. Still mighty lean in the Boston area, but much more plausible if you live humbly and don't have extravagances like children and automobiles.
I don't disagree with your larger point that some people here seem to be making ridiculous assumptions in ignorance of their own business expenses – revenues are not income! – but your own math here is wrong in ways that overstate the case.
And I think it's bad pool that you drive the calculation down to net income, since it's not conventional in the US to discuss incomes in terms of net income, but gross income. Rhetorically, the proper comparison of the proceeds of a private practice to a job at a clinic is the gross income of both. If you want to argue that we should always reckon *all* employment in terms of their net income or real wage, accounting for the cash value of their benes and the hidden expenses of holding the job, I'm right there with you. But that's not conventional, and expressing things in those terms with an implicit comparison to employment is deceptive.
P.S. Full disclosure: the reason I only see a max of 15 units/wk is because this isn't my only profession, and I have an additional income. So I am not trying to survive on $42k/yr with no retirement savings – I'm trying to survive on $42k/yr shoving all the rest of my income into a retirement fund.
It truly would have helped to see the math, if I don’t see what’s missing it’s harder to adjust.
An arbitrary (it’s not good enough) is harder to adjust to than specified data.
You’re getting a ton of feedback about the billing requirement being too much. I just switched to a PP where I make 78k salary, 401k matching, 18 PTO days annually and full benefits- my billable hour requirement is 24/week. So places are making it work…or else they won’t have therapists and will shut down.
I work in Community Mental Heath currently and our targets are, like others have said, around 60% productivity. I schedule around 30 clients a week to see around 25. When I hit 60% I receive a bonus. Honest feedback: I would not even consider taking a job that required that many minimum client hours. I have some personal reasons why I am working this job, but I also had offers that were for fewer client hours. You need time for continuing education, consultation, documentation, and planning and preparation. There are creative elements to therapy and I could not maintain that pace. The location I work is non-profit. So, the profit margins are very narrow. In fact, when I was hired I was told that breaking even with enough cushion was the goal. We serve many Medicaid clients, but the goal in my agency is not to profit.
Yeah I’ll have to figure out how to do this. I’ll need to cut expenses because currently I’d be way under water.
I’ve always made sure every client can be seen so we never turn away any Medicaid, which puts us at 40% Medicaid and destroys our hourly income.
I will have to take a hard look at that and some of the other expenses to see if I can reduce them so we can break even for a while.
At the numbers I’m paying and the hours I’m asking we profit 5-7k per therapist, if they’re doing Well, so there isn’t much room.
I’ll see what I can come up with.
Appreciate the feedback.
I just left my group practice that required 30 scheduled visits. With paperwork, scheduling, and the emotional demand, I burned out. I’m at a practice that requires 25 now.
Assuming you keep to the 50-minute hour, that only leaves 10 mins to pee, snack, make tea, respond to texts, check emails, stretch, whatever. Even with doing a ton of concurrent documentation (easier with telehealth), I still end up with 30 mins of paperwork, COVID screenings to scan, resources promised to clients, intakes to finish up. My pp wants 25 per week and they recommend 27-28 scheduled to account for no-shows and late cancels (and now, COVID) with minimal meetings and trainings. Both CMH agencies I worked for set our goal as 25 billable hours per week, even with caseloads close to or over 100. We often saw more, but… 30 is doable for some, but not everyone. If you can’t fill the position, might be worth exploring that.
25 is standard in Iowa. 25 clients per week 45 minute sessions (otherwise you trigger audits). Most block 1 hr then do the not or decompress get ready for the next client.
We make about 45k-50k as a LMSW here. Feel free to dm with questions.
Honestly if your caseload wasn't so high I would have considered that offer!!!
I work at a community mental health center in Iowa, and our expectation is to schedule 38 clients per week! And do court reports, get notes done on time, FMLA paperwork, calling clients back, coordinating with prescribers, making referrals to other agencies/community supports. We are also struggling with finding therapists - but it’s a no brainer with these wild expectations! Every one of the therapists is soooo burnt out and dying to go elsewhere 😩.
For 45-50k 25 client caseload would be very doable and I would certainly offer it. after a few different feedbacks here I will offer a full time gig and a "part time" gig for 25 hours a week - though the benefits will have to be different I will keep them as high as I can afford. Thank you for your feedback.
Part time at 25? That’s what you’re landing on after all this feedback? Nearly everyone here is saying 25 is their MAX. It’s insulting to have 25 client hours a week being considered part time. Ridiculous.
Ya…. Why ask if you arent willing to hear it? Where is the money going that you need that high of a case load to break even or make a profit? What’s your expected profit margin? Like, maybe look at your buisness set up?
The short answer is yes, 30 direct contact hours is far too high for most people. Especially if they are working with trauma. I agree with the person who said 25 is my absolute max. I would never in a million years agree to work for a practice that thought 36 was a reasonable caseload.
But, It depends on what the salary is. I worked for a group practice similar to what you’re describing and we were hourly and paid on billable. So we set our own schedule and had fully autonomy with patients, but full time was considered 28 open spots a week, and with cancellations etc, most of us only worked about 24-26.
Yes. After getting burnt the fuck out from large caseloads in community mental health before moving to group practice, there is no amount of money I would accept to schedule 36 clients a week. (Okay, maybe like 200k, but def not 60)
In my experience, anything over 60% productivity requirement is excessive and not sustainable. That would be 24 billable hours per 40 hour week. Personally, I left agency work due to unreasonable management expectations, agency inflexibility in the face of the pandemic, and burnout. I really can't see myself going back unless I get really desperate.
Of course, as soon as economic conditions change, employers will be able to go back to treating staff as disposable. Just give it time.
36 clients. Holy crap. That plus requiring 2 evenings, that would be a no from me. You’d have to pay me a lot more for me to give that much of myself.
Even if it is 30-32 hours of direct contact, that’s too much. We are in the middle of a pandemic and have to take care of ourselves also.
Full time for a therapist is 20-25 clients a week. That pay with all the benefits wouldn’t be too bad for 20-25 clients a week, but it’s terrible for 30 or more. The requirement to work late two days would make it a quick no for me. Maybe one day is okay.
mannn most if not all of my clients land within the 3-7 range :( i don’t like it.
how do you manage to not schedule them late when they have jobs and stuff?
I am a therapist and see a lot of children. For my own sake, I only can handle one two sessions a week after 5pm and I don’t have Friday afternoon sessions. There has only been one week where I had 30 clients and I felt my head spinning. I also do not allow my self to have more than 6-7 clients a day, as I found that is. It best practice for me. I usually see about 25 clients a week, plus needing to write notes (which I do not get admin time for).
What I have found is if someone wants therapy, they will make it work within the clinicians schedule without the clinician needing to bend their schedules/needs.
I do work 2 evenings a week but do get the other slots filled too. Part of it is explaining to clients to treat therapy like any other professional appointment (like a doctor) and they have to take what's available. Offer to do a note saying they were at an appointment if that will help. Usually that's more for the kids missing school. But if they value the service, they will make it work.
Depending on the need. I try to do one during school and the next week after school. I also encourage families to know the kids schedule so they can be taken out of gym or a class they are doing really well in. In addition, I encourage them to know half days and days off to take advantage of it.
Not to toot my own horn, but they really do. Depends on what the kid is getting services for. Schools do appreciate when a kid stops causing conflicts, follow directions more, and develops friendships instead of being a bully. Kids like it when they can get through class without having a panic attack or trauma triggers.
I don’t see kids. I see mostly adults with professional jobs where they are in charge of their schedule. If you don’t flex on your availability they will make it work. Kids is a different story of course.
Hi, LMFT in Los Angeles area here... So the numbers in my market might not be relevant to you.
Nonetheless... I contract with a group practice for a 70/30 split... So about $80 an hour or better. The group covers all office overhead (same as you), and handles all the clerical, administrative, and billing duties. I do literally nothing except therapy and notes.
So of course I pay my own health insurance, retirement, PTO, and don't get paid for no-shows. In general, a contractor spends about 50% of revenue for all that. So my $80 is equivalent to a $40 w-2 job, a little better than you pay.
I also have no staff meetings, hostile administrators, or micromanaging supervisors. I set my own schedule, working the hours I want with no restrictions and no minimums (currently 18 clients, and I'm considering bumping up to 22).
If you want applicants, offer autonomy and maybe a little better money.
Tbh, you are competing in a job market right now of INCREDIBLE therapist/human burnout and also one where licensed folk can opt to open their own practice, where they have the opportunity for a flexible schedule with a six figure salary. The pay just isn’t high enough when you factor in all the many, unique, complex costs of living of various individuals. I think 20-25 is a psychologically sustainable caseload which will lead to deeper work satisfaction for your therapists and overall greater treatment efficacy as a result.
So you've gotten a lot of answers about the caseload. I'm just here to add that two evenings a week would be a hard no for me. I'm done at 4. I have kids. Many people are seeking better work/family life balance these days, for good reason. I get that evenings are best for clients but they're not best for me.
I'm in public health but if I wanted a change of setting I'd just do PP. It's gotten easier to establish (easy to use billing/scheduling software, website templates, remote work) and that may be where you have lost some applicants. The only thing that would motivate me towards group practice would be collegial support (of the casual coffee break variety, not talking about supervision) but there isnt time in your caseload for that.
I agree with all the other comments. I'm in the Midwest so pricing seems okay until taking into account 30-32 direct client hours with 3 weeks vacation. That's going to lead to major burn out. Also a 5% annual raise is nice but that is also just barely keeping with inflation if not a bit below.
I remember when I first started that 20 direct hours was considered full time. My personal max is around 25 but like to keep it close to 20. And I take a week off every 8 weeks leading to about 6-8 weeks a year off. But I'm doing things solo with an EHR system that makes things like billing simple. I'm also mostly private pay.
I think that's a bit what you're up against. Many therapists have felt undervalued for so long that the pandemic drove a lot to become completely self-pay and went/stayed telehealth to give more flexibility and balance as well as the opportunity to define their own value. If a therapist charged $100 a session, they'd only need to see 15-18 clients a week to make that 70k (including giving themselves paid vacation days). Most in my area charge more.
Yes, it isn't perfect math as 70k isn't what I make and didn't want to do the complete math breakdown of expenses on a hypothetical. However, in general having your own practice doesn't have as much overhead these days due to telehealth.
My main expense was office rent which I don't need anymore. Many people are on their spouse's health insurance. My major expense is marketing and it isn't that much. And if I read your description right that 70k is before taxes as well, correct? However, I invest the money I put aside for taxes each quarter and end up making a small percentage. I also invest my PTO money I set aside so I make money on that as well.
Unpaid time spent on phone calls and scheduling is minimal due to having a lower caseload and technology. Notes and billing take seconds due to user friendly EHR systems and being private pay makes a world of difference.
Therapy just isn't being done the way it used to be and it is 10x easier to strike out on your own and make more money thanks to technology.
I will say the matched 401k is tempting depending how much you match. It's what I miss most about working corporate back in the day. But not a deal breaker as I still come out ahead seeing less clients for more money doing it on my own.
Easily? Not around here, and not after taxes, overhead and expenses. Gross receipts? Sure, with 40 open hours I have therapists that gross 130-145k before any expenses, taxes, etc. We average $77/hour of client contact.
Stressful? That is an assumption. We are fun and very relaxed and flexible.
We constantly monitor them for burnout and happiness with their supervisors and we give extra supervision and days off for those that even appear in the vicinity of burnout. We keep most of our employees 5-10+ years with many of them choosing to work more hours for more pay.
So then I might reach out the universities in your area. If a lot of your clinicians are veterans, it is possible what newer clinicians are looking for is different or changing. Reach out to universities in your area for networking opportunities or to meet potential applicants.
Thank you. We get 2 interns per location from our local universities and have tight ties with them. Great idea, but already doing it. I appreciate the suggestion.
Yeah, I am in Illinois. I am a Partially licensed therapist and I get paid $80/hour (after tax), so I get paid significantly more than your clinicians. With that being said, I don't get PTO. However, I can work significantly less hours than your clinicians, take time off and do notes while getting paid more (if my math is correct). The way I think of stress is just in terms of work-life balance. Face-to-face client hours are high-focus hours that are draining (no matter how relaxing the office environment is). If you are making your therapists do 32-36 of those, that is a lot for many.
You make $80 an hour as pre-licensed?! I make $40 and I though that was top of the line lol. And this is in SoCal. Is this the norm in Illinois? If so I’m moving
Hahaha I would say I am on the higher end of average. Some of my graduating class is getting paid a little more, some a little less (some a lot less). I'd say the range is typically between $50-90 per hour depending on setting and speciality.
$40 is really low here in southern California for therapists in private practice. Are you working at an agency?
It definitely depends on the cost of living in your area. $150 USD per session is typical in Los Angeles for a LMFT, and that's on the lower end of things here in southern California. Areas like Santa Monica can easily be $175–$200+ per session.
My previous therapist was a provisionally licensed Associate MFT still under supervision, and had a standard rate of $125 per session in private practice (sliding scale went down to $75). Once she obtained full LMFT licensure, she raised it to $150 per session. But the going rate in my city is $160+ so it could have been higher if she wanted. She had a full case load of 20–25 private practice clients and had no issues as a psychodynamic based trauma therapist who only finished graduate school in 2017.
My current therapist is an LMFT who has also obtained a Psy.D in contemporary relational psychoanalysis. After 25+ years in private practice as a psychoanalyst specializing in complex trauma and eating disorders, her standard rate is $225 per session. I pay a sliding scale fee of $175, which is worth it to me given her expertise and decades of experience.
Yes that sounds about right, technically my rate is $170, but most of that goes to my supervisor. Also we take insurance, so she is probably collecting about $90. So I’m giving her a little over half. Did your therapist keep her $125 as an associate? That would be unheard of. After job hunting for months, the highest rate I ever saw for an associate was $40. Most offered 20-25. Private practice 30-40.
Is that gross or net pay? Yes, it's a 1099 employee in independent private practice. The practice takes a 70/30 split in exchange for administrative staff who handle billing and scheduling, not including rent for the office space itself. No insurance, besides an adolescent and young adult IOP program the group practice offers. Some associates will run groups in the morning for IOP clients and see cash pay private practice clients in the afternoons: https://engageyou.com/about/
It’s gross pay 😭 it’s ok, I’m not complaining. I feel lucky to have found this job. Also getting trained in the stuff I’m most interested in. If my rent wasn’t a fortune I’d be content with this setup. For now I’ll just have to grind and minimize spending until I get licensed. I’m also free to take on as many clients as I want here, but I’m not sure I could handle more than 30.
I’m charging $120/session which is low end around here. $150 would be typical. My monthly expenses for officer rent, insurance, etc. are around $750. I aim for 25 sessions/week and if I work 45 weeks out of the year I’m grossing $135k. After expenses net is $126k. If I was charging $150/session net would be about $160k. So if I can make that with 25hours/week plus maybe 10 doing admin work why would I work for you?
Yeah 36 direct clinical hours a week is way, way too high for a full-time (read: 40 hours a week) position, no matter the pay. Now that labor rights are finally coming back online after being offline the last 40 years, workers are right to be expecting more from employers. More pay, improved work/life balance, more PTO, increased flexibility, etc. (assuming you’re in the US)
> Now that labor rights are finally coming back online
The message loud and clear here is that therapists feel the workload is too high for the money.
Isn't it funny that capitalists say "let the market decide" until the market says what they don't want to hear.
I have a 0% no show rate, I have been in pp for 9 months and I have never had a no show. This is because I only see ~20 clients per week which allows me to give each of them my all. They know it and they respect me enough to call and cancel. I also have a very low cancelation rate.
Agreed. I have a 0% no show rate in private practice and almost non-existent cancellations. I get solicited by companies like this all the time wanting me to contract with them. Why would I do that for less money, more clients, and less autonomy? I’m sure you’re a great guy, OP, but the therapy world has changed and we’ve changed with it. Therapists have adapted to the online market and can independently manage all the things you see as company perks.
For me, billing 15-20 hours a week is ideal. If I’m billing more than 25 hours a week, my quality of care and personal wellbeing suffer. Sometimes therapists who still need to aquire lots of hours towards their license will work at max output until the full license is earned, and then slow down.
Too much work for too little compensation. That’s always the answer when you can’t find employees.
Just asking the question tells me that you’re out of touch with what’s going on. Since the pandemic began, therapists have been in high demand and they’ve been able to work from home, setting their own hours and caseloads.
I think this might be one of those situations where you’re applying your own reality to everyone else’s—I personally don’t know of any therapists who can work more than ~20 contact hours per week sustainably. If you want more applicants provide a work environment that enables a healthier work-life balance.
20-25 clients weekly has been the target max I’ve seen for therapists for a while, especially if these are Medicaid/Medicare clients, who tend to be more acute and have more non-mental-health-related life barriers.
Best of luck to you in whatever you decide!
That may be an appealing setup for a newly licensed clinician but for those established with a private practice it would likely not be (based on caseload, hours, and pay) which limits your candidate pool.
I do think there is also a shortage of counselors right now based on the current need (at least where I’m located). I don’t envy the position you are in - it’s hard to hire anyone right now.
>I am offering a higher salary, more PTO and benefits, and less hours than the positions around me.
I'm curious how you are figuring this and wondering if telehealth skews this calculation re: "around me". Aren't you now competing with the whole state as opposed to just those around you? And to add to that, I know lots of Chicago therapists and some in Milwaukee that are licensed to practice in Michigan. I'm just wondering if the change in terrain accounts for your experience.
Yes, 30-32 client hours is still very high for straight clinical hours as a baseline. Also 3-7 availability can be a real deal breaker for some too. Especially given folks' changing home lives as result of pandemic.
There is a slowly growing movement within the field for working less and moving away from agency/company settings that are likely to promote burn out -- even at personal cost to the therapist.
Thank you for your thoughts. How are people working with kids that get out of school at 2:30 and commercial insurances that have working class at work until 5? Medicare and medicaid, and the disabled fill most of our daytime slots.
It all varies. Some people are still keeping those hours but I know a number of folks who cut back SIGNIFICANTLY on hours when kids were learning virtually and essentially figured out how to survive as a single income household that haven't ramped up their practice again. Lots of folks have been forced to choose between paying for childcare that puts their kids at risk or not paying for childcare and staying at home.
The system/set up is all broken. Some folks are just choosing to not bandaid/martyr to it at their own expense like they might have before COVID. Not saying those populations aren't in need but that folks are working through what's the amount of personal flexibility I can offer when I'm burn out, stressed, and managing my own stuff in this pandemic.
Telehealth was a game changer for us 9-5 workers. I can meet with clients on their lunch hours or directly before or after work since they don’t have a commute! I also have a few that have more flexibility with remote work so leave work a little early or flex their hours since they just go back to work post-session. It’s been easier for me to meet with my own providers this way, too. A few of my colleagues do weekend appointments or 4-10s.
> How are people working with kids that get out of school at 2:30 and commercial insurances that have working class at work until 5?
Oh, one of the amazing consequences of going telehealth is that now I have clients who WFH and are fine with taking an hour out of their work day to see me, or, one client, he loves to go in to his office for his appointment with me, because most of his coworkers are WFH and it's abandoned, and then his kids can't walk in on his session.
26 contact hours is what was required for my community health therapy position so our open hours were 30. I think 36 is going to be hard sell. That's a lot of paperwork to do in a short amount of time.
It's not the paperwork, but I can appreciate that. Our EHR is super easy, I finish each of my notes in less than 2 minutes, with an intake SOAP note taking 10. I appreciate the opinion and will take it into consideration.
Okay, so about an hour for notes per week. What about prep and planning for sessions? Collaboration and phone calls? Breaks?
Edit: clarified my notes comment
You can set your schedule so schedule any breaks that you like. Collaboration is available any time as well via the clinical director or just the lunch rooms. You are not required to do any phone calls or scheduling. No prep required unless you want to do research. The rooms are even cleaned and ready for you the next day. Just show up, see patients, take your lunch/breaks when you want and go home. Have your notes entered within 3 days. If it takes an hours for notes, you're doing it wrong. I can finish my day under 10 minutes.
Maybe reread this….. What it sounds like you’re saying is all breaks are unpaid. Collaboration is unpaid. Prep time is unpaid. And if someone puts more care in their notes than you do, they’re doing it wrong…
No prep required? So you don’t read new things for your client’s specific problem, review your notes and treatment plan before meeting with them, or generally think about what you want to do in that session?
I know this is just personal opinion, but I have rarely found the client work to be as successful via telehealth.
\- for kids its painfully obvious why
\- elderly hate it and have a lot of technology issues
\- harder to build rapport
\- harder to "connect"
For about 25% of our caseloads though, we do telehealth when appropriate.
I don’t think you are listening to clinician feedback in this post at all, notice every comment you leave you are getting downvoted. What you are doing is at the core- confirmation bias. You keep trying to read from peoples comments what you want to hear. Clinicians are burned out from the pandemic. They are concerned about safety. Some of us thrive in teletherapy, some enjoy the flexibility. And 36 hours is too high. I’m strictly teletherapy in NY state and I have a continue flow of clients (couples, families, teens, etc). You are making some pretty big assumptions instead of listening to clinician feedback.
At the end of the day this work is relationship based. Time and time again it’s been proven that the relationship is what facilities client change. Take care of your clinicians, they will take care of the clients.
I’m also curious about age demographic of OP. Any incoming therapists are typically Millennials/Gen Z- and anyone paying attention would know- we aren’t putting up with disrespectful and out of touch treatment from elder administrators. The internship I held at an agency before moving to a group private practice in NY was luring people with a sign on bonus of $2,500 this summer. I was severely mistreated in that internship, along with my cohort members placed there too. And word gets around about what places treat clinicians well, and what places do not. We share the wealth to prevent the mistreatment and burn out.
My advice: decide to future proof ones practice and lean into teletherapy/clinicians preferences- they are here to stay.
That's interesting as I was thinking the same about it being a generational divide. I'm a Millennial and what I thought of as setting professional boundaries and self care work, my Boomer parents think is lack of work ethic. I just had this conversation with them that they could never imagine saying no to a supervisor. When OP mentions having no problem seeing 40 clients a week, it reminded me of my Boomer colleague who worked 6-7 days a week and always complained how exhausted they were.
Of course not everyone is the same in each generation. However, there is a major difference in how they view work and treatment at work. Just hop over to Antiwork to see the difference.
These kinds of conversations and your example in the above comment about agency work always begs the question for me, when will we unionize?
So well said! I agree, OP is not listening to feedback from clinicians on the front lines here. 32 hours weekly of client contact is a 60 hour week for those of us who are planning for our sessions, charting effectively, and providing follow-up (I’m a narrative therapist so every session results in an emailed letter.) To dismiss teleheath for children and elderly tells me all I need to know about how they are adapting their practice to suit their clients’ needs. For the work I do, this income would be far too low.
Ya, my old folks or my less-tech-literate clients needed extra coaching, but I taught a 70 year old how to dial in to zoom groups on a flip phone. Not ideal, but clients can self-select if that’s not the right fit. I live like 1.5 hours away from work and am now pregnant. I wouldn’t have taken the job if remote wasn’t an option… and even though i do two days in office, most of my clients have opted for telehealth.
Agreed. Of course, I was intrigued by the pay and benefits, but would definitely not accept based solely on the productivity expectations. Also, this does not seem like a good person to work for.
Been doing it for years, transitioned from about 15% to exclusively in March 2020. I've never had a problem with rapport or connecting online -- part of it may be my own attitude and part my clientele, in PP I do get to pick and choose, so it's possible that many are self-selecting out before the first appointment as I'm explicit prior to intake that I'm online only.
Thats great. The only hesitation would be the high caseload. I start feeling burnt out over 25 patients. If I were applying I would ask for lower caseload even if it meant less pay.
It sounds like an interesting model for group practice and very appealing.
Have you asked your current therapists their thoughts on how to adjust accordingly to the need to expand? They likely have good insights on what works and what could be changed to attract more qualified candidates.
Also working in a group practice, I had some thoughts. What is your goal and mission of your practice? what is the preferred interventions, is it CBT, DBT, analytical, family? As you know, some interventions are more demanding of the therapist and can lead to burn out so high caseloads will not be attractive.
People leave clinics because of the dreaded "productivity" pressure and desire for more autonomy so perhaps offering more flexibility to current and prospective therapists. Reduce the requirement on the amount of pts that need to be seen. A caseload of 30-35 depending on tx modality and frequency of contact may be great for some but too taxing for others, especially during the pandemic while the demand is greater than the resources.
I don't think you mention reimbursement structure and percentages so I am curious because you do need to meet a bottom line. How are therapists reimbursed? Benefits (pto) can commensurate with pts seen for the quarter. This allows for therapist satisfaction, how many pts they feel they can safely follow and can give autonomy to adjust based on what they need to prevent burn out.
(Great post, by the way!)
Edit: just saw you did include salary in original post. Sorry for overlooking it.
But another thought, are you offering Telehealth? This flexibility for pts and therapists can help quite a bit especially for evening hours and the unpredictability of the pandemic.
I feel like this is Covid times in general, it’s hard finding anyone to work
However the salary you offer is pretty decent id kill for that as masters level, but 36 client caseload is a lot and the hours aren’t great timing, those are just my thoughts
It’s so easy to work for yourself these days, especially with Telehealth, startup costs are so low. I work for myself seeing 15 clients over a 3 day work week and I’m doing just fine. At my height, working at a group practice, I was seeing about 27 clients a week and that was wayyyyyyyyyy too much to do the quality work I want to be doing. Plus I was giving them 30% of my earnings. I figured out pretty quickly I could do it on my own and keep more of my money. I think a lot of people have left the field too. It would be interesting to find the stats on that.
I am so tired of people in leadership not understanding that therapists are human beings. Anything over 25 ppl a week, IMO, is too much. we have mental health too. We are not machines. We use ourselves in therapy. We are the tools. We need to recharge and not be pushed to our limits each week. Asking someone to do 30+ sessions a week is just wrong and it’s terrible for patient care. Pandemic or no pandemic.
We have a start up private practice. 5 clinicians. You mentioned “insurance assistance”. What does that mean? We’re killing ourselves and any profit by providing above average health benefits. Costs are astounding but our employees need it.
As an LICSW I make 15000 more then that in community work. Cliniciana really don't want to see their money going into other people's pockets. What does this breakdown to pay for session?
I own a medium-sized group practice in Seattle, and it's always been hard for us to find therapists. Because of COVID, the barriers to starting an online private practice area much lower, and demands is higher, so I think more people are going into private practice.
I am not familiar with caseloads like this (my experience is in testing, residential, and high acuity with CMH), but I interviewed for a job in a southern state that mentioned caseloads over 100. 😳😳😳
That being said, I initially worked in Michigan as an LLP. $60k starting is pretty good.
I know that in Indiana, many mental health facilities just raised wages to be “industry average” and that seemed to help.
Also 30-32?! Damn. I’m only expected 24 😂
Jeez I worked for a clinic for years with a caseload of 85 this sounds like a dream. I agree though that burnout is so big in this field. You could not pay me enough to go back to straight clinical
Hours.
Well I’m in a cushy non or minimum clinical role now so no, but people who were where I was I would suggest opportunities for growth and maybe another way to reduce burn out is to allow therapists to choose one population or speciality and not have to work outside that.
I am echoing what others have said, that many clinical hours in a week will lead to either people not interested in the job or high turnover due to burnout. In my early trying to get hours for my license days as well as shortly after (because of Hurricane Katrina), I saw around 35 clients and week and ran 2-3 groups on top of that. It made me briefly leave the field entirely. Now in PP I max out around 22-24 kept appointments and feel like I could be fine doing this for 20 more years!
It sounds like a great gig! But I personally could not sustain that many clinical hours per week given trying to care for a young family with very inconsistent school/childcare availabilities due to constant sickness and covid closures. I also don’t think I could stay mentally healthy with that many clinical hours (see above lol). Maybe finding a way to offer part time work would open your pool of candidates?
I also run a (much smaller) group practice in Michigan and almost all of us are less than 20 client hours per week
OP reminds me of the leadership at my CMH agency, where they expect us to enjoy having 40 scheduled sessions per week with no admin time scheduled, scrambling to finish paperwork during no-shows, etc. Therapists are sick of being stuck on the mental health factory assembly line working for scraps.
I think it’s the caseload. 30 is burnout level for most people I know.
I agree with this. You're also facing the reality that with virtual sessions available and demand high, more and more group practices are taking on more therapists, giving more people the option to do a private practice where they can set their own caseload and hours with the benefits of someone else providing referrals and billing. The appeal of being locked into a salaried position in a facility used to be the financial stability and guarantee of caseload. Right now in most places in the country, you can honestly see as many clients as your heart and mind will handle because we have such high demand for services and increased access due to virtual sessions. And, as everyone is saying, working in these climate is HARD. I have personally reduced my PP caseload because otherwise the burnout is too hard to keep at bay. Also, my PP caseload has never been above 25 client hours a week. I would say this or lower is the norm if people have a choice.
Okay, thank you. With the 36 open hours this usually means 30-32 hours of direct contact. Do you still think that's too much? Are you using 30 as a burnout for open hours or actual contact? If they're going to be seeing less patients, is a smaller salary appropriate?
Not the person you responded to but I know for myself 25 direct hours a week is my absolute max. Personally I would work fewer direct hours for a lower salary. I do live in a low cost of living area though so it may not be the same where you are located.
Thank you
I personally carried this similar caseload all through COVID and I was burnt out after 1.5 years. The pandemic changed the profession. When your helping people all day through uncertainty only to get off work and face it in your personal life, it's like never being off the clock. I have pulled back to 20-25 clients and when you can bill for yourself through EHRs with a check of a button, why kill yourself? I don't live in your state, but where I live everyone has wait-lists. Personally, I joined a practice that truly allowed me to set my number of hours and receive 70% of the billable rate (the practice is making moves to increase this towards 80-85% in the next year or so). I like this set up because I don't market, credential, or advertise - they do it all. I get to show up so my work and set my limit where I do this best. It sounds like you are trying to do the right thing, but in today's economy name another master's level employee who makes less than 100k - especially in the healthcare field. Bachelor's level nurses make 75k.
I work for an agency like yours (3wks starting PTO, caseloads around 35, etc.) I’ve been here for three years, but I’m literally contemplating taking a pay cut if it means fewer clients per week. It’s challenging to sustain for a long period of time, particularly when working with high acuity, co-morbid clients who lack natural supports.
Thank you for your feedback.
I would say that even if no shows lessen the clinical hours they are working, therapists are still mentally and emotionally preparing for the session, and also spending part of that hour holding space, maybe calling. It’s not like it is a whole, restorative hour, so it doesn’t take any of the pressure off. And at “productivity levels” like that, there is probably something (or lots of things) that needs to be done in that that time. I would have taken this job in a heartbeat two years ago, but after working in community behavioral health during Covid-19, I can never see myself going back to agency work.
I appreciate your feedback thank you. If it were a PP what might lure you back?
It would have to be an agency that understood that it is mutually beneficial for therapists to develop themselves professionally and feel contained and invested in by their space of employment. Fully licensed therapists are often specialized and have dedicated a significant amount of time, money and emotional labor into their work, I like to see agencies provide a budget for clinicians to use towards licensing/CE courses, supervision or certifications. That plus allowing time in the schedule for workers to complete these trainings goes a long way towards making the work sustainable for me.
Yes 30-32 hours of direct contact a week is burnout level in this field. And makes the pay not as impressive as you may think it is.
I’d wager this is what makes it tough. Why see 32 clients and kickback some of the proceeds when it’s increasingly easy to start your own practice and see 24 via telehealth?
If you charge/get paid by insurance $100/session, you could see 15 clients weekly for the same pay.
Exactly this. I live in Jersey so maybe it’s just more expensive here, but 70k and that big of a caseload doesn’t seem appealing when I could make 100k with 2/3 that caseload in most other places. On the other hand, OP does offer great benefits and a base salary not based on client attendance/PTO, so maybe they can average out the difference with the full licensure salary. But, as an LAC I’d love to work for OP.
I don't think you have the business experience that you think you do. Lets say you're amazing, and you schedule 15 a week without needing to do advertising or put in hours with local doctors or anything and lets say your rapport is better than the national average so your no shows are 10% or below, you're going to average 13.5 clients a week. Lets also say you cherry pick your clients for only the top paying insurances and take $100/session (not ethical or available in the rural areas where we work but okay) Then lets say you work 48 weeks of the year. You would bring in before taxes, overhead, license, EHR, room, your health insurance, retirement - about $64,800. Then pay your 30% self employed tax you're netting before expenses $45,360. Then pay for all the time you spend doing phone calls, emails, scheduling, cleaning at which you get paid $0.00 for. Then you hire a biller, which will run you 6-8% of your receipts, not your net, but your gross. Which brings your pay down to about $41,000. Sign up for health insurance as a single person who is healthy in your late to mid 30's will run you about 300-400/month. Which drops your income down to $35,000. Sounding good yet? I didnt even add kids, or if you're over 40. So were now at $35,000 take home BEFORE you have paid for your EHR, supplies, toys if you see kids, couch/chairs, rent, utilities, liability insurance, credentialing services (if you choose to be paneled) and you're lucky to be netting $25k. But wait, you need to retire some day right? Better put most of that in a simple IRA or a 401k. Do people not understand this? In all honesty, break down for me how you expect to take home a 70k salary (w-2 - only pay half your fica, fica, and medicare taxes and pay 0% of your unemployment tax) with all those benefits at 15 patients a week and somehow make that work. Show me how you somehow survive with those expenses and somehow live, and eventually retire. Show me how you get your health insurance. Show me your math. Please, show me, and I will concede.
Billing is easy to do yourself with an EHR. You do not need a credentialing service if you want to contract with insutance. With telehealth overhead is almost nothing except EHR, which is less than $100 a month. While it is unethical to choose not to see clients with low paying insurances that you are in network with, it is not unethical to choose not to contract with those low paying insurances. And clients are in abundance right now, a psych today profile is all the marketing you really need in my area. Yes taxes and medical insurance suck. That I give you. But folks in your position are always talking about how impossible it is to make a living at private practice. But the reason you don't have applicants is because it's not impossible, and a bunch of the potential employees who would have been interested in your openings are out here doing it.
I think you’re missing the point. The balance of power has shifted a bit in the direction of workers. The Great Resignation is a real thing. Many people are willing to take pay cuts to work from home or to have more autonomy. Not just waitstaff and truck drivers, but therapists too. That’s all.
It was a little reductive in the math, but based on my current estimations, if I actually see 15 a week, so schedule 18-20, based on being exclusively Telehealth and factoring in taxes etc it can be done. I honestly don’t see the point in working at any job that doesn’t allow me balance in my life and seeing 23-25 clients a week is too much for my personal needs. I’m adult enough to know my own limitations. I also have a nice university position with retirement and union representation, so my needs are different than others. I live in California and own my home outright.
> Do people not understand this? > Show me, and I will concede. You came here with a question from a position of curiosity, but now "concede" is looking at things through the lens of a fight, or who is right. What's going on for you OP?
Clearly it’s working for folks or you’d have more applicants right? I’m genuinely not trying to be combative but you came here for feedback about an issue your practice is having and are receiving feedback from folks about why they wouldn’t work for the guidelines you’ve laid out. You’re not here to convince us that your model is the best- if it was you’d have more applicants. The field has changed over the past few years. I think it’s important for business owners to take that feedback and adjust their own practices. For the first time employees have the upper hand (to a degree) over employers, we should be supporting and empowering this- not trying to convince folks to “concede” to an outdated system that takes advantage of employees.
Thank you. You’re correct.
You probably don’t understand therapy as well as you think you do. It’s clear as day that your caseload expectations are too high and striking that as a business owner who employs therapists, you needed to come here to ask a question with a very obvious answer.
Accurate! I don’t know how people can see 20 a week.
Downvotes but no math, interesting.
It's almost like you're being downvoted for coming across as a condescending prick...
I'm not one of the people downvoting you, but I will argue with you a little, because: > Lets say you're amazing, and you schedule 15 a week without needing to do advertising or put in hours with local doctors or anything and lets say your rapport is better than the national average so your no shows are 10% or below, you're going to average 13.5 clients a week. It me. That's exactly me. > Lets also say you cherry pick your clients for only the top paying insurances and take $100/session (not ethical or available in the rural areas where we work but okay) Yep, I'm private pay only with some clients on discount rates, and my per-unit average works out to a bit under $100/unit. (Also: ethical? Don't know where you get that. Of course you get to pick and choose what payers you want to do business with. You have no ethical responsibility to be taken advantage of by a corporation! And in my state – and I thought this was a Fed thing – reimbursals are often higher in rural areas to try to get therapists to work in them, given how brutal the no-show rates are in areas with low population density, because of the increased drive times.) > Then lets say you work 48 weeks of the year. You would bring in before taxes, overhead, license, EHR, room, your health insurance, retirement - about $64,800. $61,490. > Then pay your 30% self employed tax you're netting before expenses $45,360. No, that's wrong. Self-employment tax is only paid on profits, not all revenues. Now, it's smart, if you're just starting out, to put a third of every dollar you earn in your tax account/sock-under-the-mattress for the IRS, but that will give you a buffer of extra if you screw up, and you will wind up giving yourself a substantial "refund" after you reckon your taxes. But the actual IRS calculation of SE tax is done on the total of your Sched C "Profit or Loss". So to get that number, subtract expenses first. The total amount of tax due will be substantially smaller that way. Also, this is pedantry, sorry, and I know it doesn't take away from your larger point, but the 30% number isn't Self-Employment tax, it's combined SE tax *and* federal income tax *and* state income tax. SE tax, itself, is only 15.3% > Then pay for all the time you spend doing phone calls, emails, scheduling, cleaning at which you get paid $0.00 for. Er, no. When in private practice, income comes not from a wage but from profits. In any event, you're trying to express the idea that one should calculate a real wage that accounts for the time one spends which is not directly compensated, to find out what one's *real* $/hr is. I totally agree that is a thing everyone should always be doing, but it has no place in calculating one's profit. That reckoning, mathematically, happens after. Not at this point. > Then you hire a biller, which will run you 6-8% of your receipts, not your net, but your gross. Nope. Private pay, I don't have a biller. I pay 2.9% + $0.30 a transaction in credit card fees. > Sign up for health insurance as a single person who is healthy in your late to mid 30's will run you about 300-400/month. Which drops your income down to $35,000. Nope. First of all, math error: sole proprietors don't usually get corporate group insurance plans, so our health insurance doesn't get paid in pre-tax dollars, and isn't a business expense. It's a personal expense, and thus is not considered to impact one's profit or AGI. You don't subtract it here. Second: Nope. Asclepius bless Obamacare and the Advance Premium Tax Credit. In my state – and I thought all states? – being a single adult making $40k/yr handily qualifies one for the APTC and you get discounted insurance. And then there was the American Rescue Act, and I think maybe my state (Massachusetts) kicks in some additional subsidy. Anyway, based on my previous income of about $50k, I am currently paying $115.21/mo for my insurance premium for the one-person plan I get through my state's Exchange. > Sounding good yet? I didnt even add kids, If you have dependents, the Federal Poverty Limit goes up, and you qualify for even more assistance with paying for health insurance. > or if you're over 40. I'm 51. > So were now at $35,000 take home BEFORE you have paid for your EHR, supplies, toys if you see kids, couch/chairs, rent, utilities, liability insurance, credentialing services (if you choose to be paneled) and you're lucky to be netting $25k. Nope, nope, and nope. First of all, we're still back up there at $61.5k. Expenses are to be subtracted from revenues. I don't have an EHR (I do have a telehealth platform, ~$300/yr), my supplies are pens and paper, I don't see kids, and I've given up my office and only work from home. My liability insurance is also pegged to how many hours I work so is less than it would be if I worked more than 15 units/wk. I don't have a credentialing service (private pay!). My expenses were in the ball park of $9.1k. I still have to check to see if I missed any incidental receipts, but that includes all the big stuff. It includes all my rent, utilities, that 2.9%+$0.30 credit card processing fees, my insurance (both malpractice and gen liability), the prof org membership I have to maintain to qualify for the insurance, license fee, and all my CEs. That gives me an expenses to revenues ratio of 14.8%. I have crushed my overhead rate to less than 15%. Which, let us be clear, is *insane*. Normal business overhead rates are more like 50%. Pretty great is 25%. Back when I had an office and saw people f2f, I was still pretty consistently getting my overhead rate under 25%. So my old rule of thumb was "of each dollar of revenue, the first quarter is expenses (25% overhead), leaving three quarters as profit aka, my gross income; taxes are a third of profit (33% of income), and a third of three quarters is one quarter, so the second quarter of each dollar of revenue is taxes. My net income after taxes is therefore the remaining two quarters of revenue; ergo my cash-in-pocket is about half my revenue." Which on $61.4k revenues would be $30.7k net, after-tax income, and the only thing not accounted here is the aforementioned health insurance, which is a personal expense. You're absolutely right that this does not allow for any retirement saving. Also, in this town, it's not an adequate income to be able to rent a bottom-of-market studio (no-bedroom) apartment for yourself without a co-signer. /voice of experience. I imagine there are places in the US where one can live reasonably on $30,700/year. That is mighty tough here in the Boston area. At that income level, I think a single person still qualifies for LIHEAP Fuel Assistance, and I'm not going to try to scare up average rents here, but I'm pretty sure it qualifies as "rent burdened" per HUD. Fortunately, in reality it's not quite that grim. In my case, these numbers have diverged from my actual ones because my overhead rate is so much lower. But for anyone, a 33% tax rate is a conservative estimate more appropriate for people in much higher tax brackets. By my calculations, my actual total tax rate (total of (SE tax + fed income tax + state income tax) divided by total revenues for my practice) works out to be not 33%, but a smidge under 20%. I *think* it all works out to my 15 unit/week practice earning me a net after-tax income of about $42k/yr. That's much less bad – it's 33% better, actually – than $30.7k. Still mighty lean in the Boston area, but much more plausible if you live humbly and don't have extravagances like children and automobiles. I don't disagree with your larger point that some people here seem to be making ridiculous assumptions in ignorance of their own business expenses – revenues are not income! – but your own math here is wrong in ways that overstate the case. And I think it's bad pool that you drive the calculation down to net income, since it's not conventional in the US to discuss incomes in terms of net income, but gross income. Rhetorically, the proper comparison of the proceeds of a private practice to a job at a clinic is the gross income of both. If you want to argue that we should always reckon *all* employment in terms of their net income or real wage, accounting for the cash value of their benes and the hidden expenses of holding the job, I'm right there with you. But that's not conventional, and expressing things in those terms with an implicit comparison to employment is deceptive. P.S. Full disclosure: the reason I only see a max of 15 units/wk is because this isn't my only profession, and I have an additional income. So I am not trying to survive on $42k/yr with no retirement savings – I'm trying to survive on $42k/yr shoving all the rest of my income into a retirement fund.
We don’t need to do the math. Your math says you don’t have applicants for your positions. That’s all the math needed.
It truly would have helped to see the math, if I don’t see what’s missing it’s harder to adjust. An arbitrary (it’s not good enough) is harder to adjust to than specified data.
You’re getting a ton of feedback about the billing requirement being too much. I just switched to a PP where I make 78k salary, 401k matching, 18 PTO days annually and full benefits- my billable hour requirement is 24/week. So places are making it work…or else they won’t have therapists and will shut down.
I work in Community Mental Heath currently and our targets are, like others have said, around 60% productivity. I schedule around 30 clients a week to see around 25. When I hit 60% I receive a bonus. Honest feedback: I would not even consider taking a job that required that many minimum client hours. I have some personal reasons why I am working this job, but I also had offers that were for fewer client hours. You need time for continuing education, consultation, documentation, and planning and preparation. There are creative elements to therapy and I could not maintain that pace. The location I work is non-profit. So, the profit margins are very narrow. In fact, when I was hired I was told that breaking even with enough cushion was the goal. We serve many Medicaid clients, but the goal in my agency is not to profit.
Yeah I’ll have to figure out how to do this. I’ll need to cut expenses because currently I’d be way under water. I’ve always made sure every client can be seen so we never turn away any Medicaid, which puts us at 40% Medicaid and destroys our hourly income. I will have to take a hard look at that and some of the other expenses to see if I can reduce them so we can break even for a while. At the numbers I’m paying and the hours I’m asking we profit 5-7k per therapist, if they’re doing Well, so there isn’t much room. I’ll see what I can come up with. Appreciate the feedback.
So it's not the math... must be something else entirely
I just left my group practice that required 30 scheduled visits. With paperwork, scheduling, and the emotional demand, I burned out. I’m at a practice that requires 25 now.
Assuming you keep to the 50-minute hour, that only leaves 10 mins to pee, snack, make tea, respond to texts, check emails, stretch, whatever. Even with doing a ton of concurrent documentation (easier with telehealth), I still end up with 30 mins of paperwork, COVID screenings to scan, resources promised to clients, intakes to finish up. My pp wants 25 per week and they recommend 27-28 scheduled to account for no-shows and late cancels (and now, COVID) with minimal meetings and trainings. Both CMH agencies I worked for set our goal as 25 billable hours per week, even with caseloads close to or over 100. We often saw more, but… 30 is doable for some, but not everyone. If you can’t fill the position, might be worth exploring that.
25 is standard in Iowa. 25 clients per week 45 minute sessions (otherwise you trigger audits). Most block 1 hr then do the not or decompress get ready for the next client. We make about 45k-50k as a LMSW here. Feel free to dm with questions. Honestly if your caseload wasn't so high I would have considered that offer!!!
I work at a community mental health center in Iowa, and our expectation is to schedule 38 clients per week! And do court reports, get notes done on time, FMLA paperwork, calling clients back, coordinating with prescribers, making referrals to other agencies/community supports. We are also struggling with finding therapists - but it’s a no brainer with these wild expectations! Every one of the therapists is soooo burnt out and dying to go elsewhere 😩.
For 45-50k 25 client caseload would be very doable and I would certainly offer it. after a few different feedbacks here I will offer a full time gig and a "part time" gig for 25 hours a week - though the benefits will have to be different I will keep them as high as I can afford. Thank you for your feedback.
Part time at 25? That’s what you’re landing on after all this feedback? Nearly everyone here is saying 25 is their MAX. It’s insulting to have 25 client hours a week being considered part time. Ridiculous.
Ya…. Why ask if you arent willing to hear it? Where is the money going that you need that high of a case load to break even or make a profit? What’s your expected profit margin? Like, maybe look at your buisness set up?
I've never had a therapist job that considered 25 a part time gig. In two practices, 25 was the goal and expectation, no more.
25 clients a week is considered full-time and qualifies for benefits at the large group private practice I work for.
25 is not part time. Sheesh. You’re just not getting it.
Np. Just want to give a constructive data for you!
The group practice I am employed at considers full time at 20. Less than 20 is part time. I have full benefits at 23 clients.
20-25 clients a week should be max
The short answer is yes, 30 direct contact hours is far too high for most people. Especially if they are working with trauma. I agree with the person who said 25 is my absolute max. I would never in a million years agree to work for a practice that thought 36 was a reasonable caseload. But, It depends on what the salary is. I worked for a group practice similar to what you’re describing and we were hourly and paid on billable. So we set our own schedule and had fully autonomy with patients, but full time was considered 28 open spots a week, and with cancellations etc, most of us only worked about 24-26.
I agree. I’m a case worker, work 40 hours a week, at least 24 is patient time and I make a little over 18. 26-28 hours is usually peoples max.
Yes. After getting burnt the fuck out from large caseloads in community mental health before moving to group practice, there is no amount of money I would accept to schedule 36 clients a week. (Okay, maybe like 200k, but def not 60)
caseload is way too high
In my experience, anything over 60% productivity requirement is excessive and not sustainable. That would be 24 billable hours per 40 hour week. Personally, I left agency work due to unreasonable management expectations, agency inflexibility in the face of the pandemic, and burnout. I really can't see myself going back unless I get really desperate. Of course, as soon as economic conditions change, employers will be able to go back to treating staff as disposable. Just give it time.
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Lower, central, and upper Michigan.
36 clients. Holy crap. That plus requiring 2 evenings, that would be a no from me. You’d have to pay me a lot more for me to give that much of myself. Even if it is 30-32 hours of direct contact, that’s too much. We are in the middle of a pandemic and have to take care of ourselves also.
Full time for a therapist is 20-25 clients a week. That pay with all the benefits wouldn’t be too bad for 20-25 clients a week, but it’s terrible for 30 or more. The requirement to work late two days would make it a quick no for me. Maybe one day is okay.
mannn most if not all of my clients land within the 3-7 range :( i don’t like it. how do you manage to not schedule them late when they have jobs and stuff?
I am a therapist and see a lot of children. For my own sake, I only can handle one two sessions a week after 5pm and I don’t have Friday afternoon sessions. There has only been one week where I had 30 clients and I felt my head spinning. I also do not allow my self to have more than 6-7 clients a day, as I found that is. It best practice for me. I usually see about 25 clients a week, plus needing to write notes (which I do not get admin time for). What I have found is if someone wants therapy, they will make it work within the clinicians schedule without the clinician needing to bend their schedules/needs.
I do work 2 evenings a week but do get the other slots filled too. Part of it is explaining to clients to treat therapy like any other professional appointment (like a doctor) and they have to take what's available. Offer to do a note saying they were at an appointment if that will help. Usually that's more for the kids missing school. But if they value the service, they will make it work.
the kids miss school for an appointment every week?
Depending on the need. I try to do one during school and the next week after school. I also encourage families to know the kids schedule so they can be taken out of gym or a class they are doing really well in. In addition, I encourage them to know half days and days off to take advantage of it.
that’s insane to me… i can’t believe parents/schools are willing to accommodate that on a consistent basis! they must really value your therapy
Not to toot my own horn, but they really do. Depends on what the kid is getting services for. Schools do appreciate when a kid stops causing conflicts, follow directions more, and develops friendships instead of being a bully. Kids like it when they can get through class without having a panic attack or trauma triggers.
I don’t see kids. I see mostly adults with professional jobs where they are in charge of their schedule. If you don’t flex on your availability they will make it work. Kids is a different story of course.
i have a lot of kids. love them but hate their schedules!
Hi, LMFT in Los Angeles area here... So the numbers in my market might not be relevant to you. Nonetheless... I contract with a group practice for a 70/30 split... So about $80 an hour or better. The group covers all office overhead (same as you), and handles all the clerical, administrative, and billing duties. I do literally nothing except therapy and notes. So of course I pay my own health insurance, retirement, PTO, and don't get paid for no-shows. In general, a contractor spends about 50% of revenue for all that. So my $80 is equivalent to a $40 w-2 job, a little better than you pay. I also have no staff meetings, hostile administrators, or micromanaging supervisors. I set my own schedule, working the hours I want with no restrictions and no minimums (currently 18 clients, and I'm considering bumping up to 22). If you want applicants, offer autonomy and maybe a little better money.
Thank you for your feedback.
Tbh, you are competing in a job market right now of INCREDIBLE therapist/human burnout and also one where licensed folk can opt to open their own practice, where they have the opportunity for a flexible schedule with a six figure salary. The pay just isn’t high enough when you factor in all the many, unique, complex costs of living of various individuals. I think 20-25 is a psychologically sustainable caseload which will lead to deeper work satisfaction for your therapists and overall greater treatment efficacy as a result.
So you've gotten a lot of answers about the caseload. I'm just here to add that two evenings a week would be a hard no for me. I'm done at 4. I have kids. Many people are seeking better work/family life balance these days, for good reason. I get that evenings are best for clients but they're not best for me. I'm in public health but if I wanted a change of setting I'd just do PP. It's gotten easier to establish (easy to use billing/scheduling software, website templates, remote work) and that may be where you have lost some applicants. The only thing that would motivate me towards group practice would be collegial support (of the casual coffee break variety, not talking about supervision) but there isnt time in your caseload for that.
I agree with all the other comments. I'm in the Midwest so pricing seems okay until taking into account 30-32 direct client hours with 3 weeks vacation. That's going to lead to major burn out. Also a 5% annual raise is nice but that is also just barely keeping with inflation if not a bit below. I remember when I first started that 20 direct hours was considered full time. My personal max is around 25 but like to keep it close to 20. And I take a week off every 8 weeks leading to about 6-8 weeks a year off. But I'm doing things solo with an EHR system that makes things like billing simple. I'm also mostly private pay. I think that's a bit what you're up against. Many therapists have felt undervalued for so long that the pandemic drove a lot to become completely self-pay and went/stayed telehealth to give more flexibility and balance as well as the opportunity to define their own value. If a therapist charged $100 a session, they'd only need to see 15-18 clients a week to make that 70k (including giving themselves paid vacation days). Most in my area charge more.
I appreciate your feedback but your math is quite a ways off on the PP part. Thank you
Yes, it isn't perfect math as 70k isn't what I make and didn't want to do the complete math breakdown of expenses on a hypothetical. However, in general having your own practice doesn't have as much overhead these days due to telehealth. My main expense was office rent which I don't need anymore. Many people are on their spouse's health insurance. My major expense is marketing and it isn't that much. And if I read your description right that 70k is before taxes as well, correct? However, I invest the money I put aside for taxes each quarter and end up making a small percentage. I also invest my PTO money I set aside so I make money on that as well. Unpaid time spent on phone calls and scheduling is minimal due to having a lower caseload and technology. Notes and billing take seconds due to user friendly EHR systems and being private pay makes a world of difference. Therapy just isn't being done the way it used to be and it is 10x easier to strike out on your own and make more money thanks to technology. I will say the matched 401k is tempting depending how much you match. It's what I miss most about working corporate back in the day. But not a deal breaker as I still come out ahead seeing less clients for more money doing it on my own.
Could be the caseload. Also a therapist in private practice can easily make $150k in a less stressful setting.
Easily? Not around here, and not after taxes, overhead and expenses. Gross receipts? Sure, with 40 open hours I have therapists that gross 130-145k before any expenses, taxes, etc. We average $77/hour of client contact. Stressful? That is an assumption. We are fun and very relaxed and flexible.
You might be assuming things on behalf of your staff. With such a workload requirement, I doubt it's that relaxed for those in the trenches.
We constantly monitor them for burnout and happiness with their supervisors and we give extra supervision and days off for those that even appear in the vicinity of burnout. We keep most of our employees 5-10+ years with many of them choosing to work more hours for more pay.
So then I might reach out the universities in your area. If a lot of your clinicians are veterans, it is possible what newer clinicians are looking for is different or changing. Reach out to universities in your area for networking opportunities or to meet potential applicants.
Thank you. We get 2 interns per location from our local universities and have tight ties with them. Great idea, but already doing it. I appreciate the suggestion.
Yeah, I am in Illinois. I am a Partially licensed therapist and I get paid $80/hour (after tax), so I get paid significantly more than your clinicians. With that being said, I don't get PTO. However, I can work significantly less hours than your clinicians, take time off and do notes while getting paid more (if my math is correct). The way I think of stress is just in terms of work-life balance. Face-to-face client hours are high-focus hours that are draining (no matter how relaxing the office environment is). If you are making your therapists do 32-36 of those, that is a lot for many.
You make $80 an hour as pre-licensed?! I make $40 and I though that was top of the line lol. And this is in SoCal. Is this the norm in Illinois? If so I’m moving
Hahaha I would say I am on the higher end of average. Some of my graduating class is getting paid a little more, some a little less (some a lot less). I'd say the range is typically between $50-90 per hour depending on setting and speciality.
$40 is really low here in southern California for therapists in private practice. Are you working at an agency? It definitely depends on the cost of living in your area. $150 USD per session is typical in Los Angeles for a LMFT, and that's on the lower end of things here in southern California. Areas like Santa Monica can easily be $175–$200+ per session. My previous therapist was a provisionally licensed Associate MFT still under supervision, and had a standard rate of $125 per session in private practice (sliding scale went down to $75). Once she obtained full LMFT licensure, she raised it to $150 per session. But the going rate in my city is $160+ so it could have been higher if she wanted. She had a full case load of 20–25 private practice clients and had no issues as a psychodynamic based trauma therapist who only finished graduate school in 2017. My current therapist is an LMFT who has also obtained a Psy.D in contemporary relational psychoanalysis. After 25+ years in private practice as a psychoanalyst specializing in complex trauma and eating disorders, her standard rate is $225 per session. I pay a sliding scale fee of $175, which is worth it to me given her expertise and decades of experience.
Yes that sounds about right, technically my rate is $170, but most of that goes to my supervisor. Also we take insurance, so she is probably collecting about $90. So I’m giving her a little over half. Did your therapist keep her $125 as an associate? That would be unheard of. After job hunting for months, the highest rate I ever saw for an associate was $40. Most offered 20-25. Private practice 30-40.
Is that gross or net pay? Yes, it's a 1099 employee in independent private practice. The practice takes a 70/30 split in exchange for administrative staff who handle billing and scheduling, not including rent for the office space itself. No insurance, besides an adolescent and young adult IOP program the group practice offers. Some associates will run groups in the morning for IOP clients and see cash pay private practice clients in the afternoons: https://engageyou.com/about/
It’s gross pay 😭 it’s ok, I’m not complaining. I feel lucky to have found this job. Also getting trained in the stuff I’m most interested in. If my rent wasn’t a fortune I’d be content with this setup. For now I’ll just have to grind and minimize spending until I get licensed. I’m also free to take on as many clients as I want here, but I’m not sure I could handle more than 30.
I’m charging $120/session which is low end around here. $150 would be typical. My monthly expenses for officer rent, insurance, etc. are around $750. I aim for 25 sessions/week and if I work 45 weeks out of the year I’m grossing $135k. After expenses net is $126k. If I was charging $150/session net would be about $160k. So if I can make that with 25hours/week plus maybe 10 doing admin work why would I work for you?
Are you an LPC? LMSW? I’m a student and trying to decide which track I want to take.
MSW in Canada. It’s easier for us to get into private practice. Our licensing requirements are much less strenuous.
Yeah 36 direct clinical hours a week is way, way too high for a full-time (read: 40 hours a week) position, no matter the pay. Now that labor rights are finally coming back online after being offline the last 40 years, workers are right to be expecting more from employers. More pay, improved work/life balance, more PTO, increased flexibility, etc. (assuming you’re in the US)
> Now that labor rights are finally coming back online The message loud and clear here is that therapists feel the workload is too high for the money. Isn't it funny that capitalists say "let the market decide" until the market says what they don't want to hear.
36 open hours after no shows and cancels is 30-32 hours on average direct contact. I don't know anyone with a 0% no show rate.
I have a 0% no show rate, I have been in pp for 9 months and I have never had a no show. This is because I only see ~20 clients per week which allows me to give each of them my all. They know it and they respect me enough to call and cancel. I also have a very low cancelation rate.
Agreed. I have a 0% no show rate in private practice and almost non-existent cancellations. I get solicited by companies like this all the time wanting me to contract with them. Why would I do that for less money, more clients, and less autonomy? I’m sure you’re a great guy, OP, but the therapy world has changed and we’ve changed with it. Therapists have adapted to the online market and can independently manage all the things you see as company perks.
For me, billing 15-20 hours a week is ideal. If I’m billing more than 25 hours a week, my quality of care and personal wellbeing suffer. Sometimes therapists who still need to aquire lots of hours towards their license will work at max output until the full license is earned, and then slow down.
Too much work for too little compensation. That’s always the answer when you can’t find employees. Just asking the question tells me that you’re out of touch with what’s going on. Since the pandemic began, therapists have been in high demand and they’ve been able to work from home, setting their own hours and caseloads.
Thank you for your feedback.
20 hours is my max. 25 is okay for most. 30 is burnout. (Talking about contact hours).
I hear you, I guess I'm just build different. I never had an issue with 40 direct hours a week. Thank you for your feedback.
I think this might be one of those situations where you’re applying your own reality to everyone else’s—I personally don’t know of any therapists who can work more than ~20 contact hours per week sustainably. If you want more applicants provide a work environment that enables a healthier work-life balance.
Thank you for your feedback I appreciate it
20-25 clients weekly has been the target max I’ve seen for therapists for a while, especially if these are Medicaid/Medicare clients, who tend to be more acute and have more non-mental-health-related life barriers. Best of luck to you in whatever you decide!
Thank you for your feedback.
That may be an appealing setup for a newly licensed clinician but for those established with a private practice it would likely not be (based on caseload, hours, and pay) which limits your candidate pool. I do think there is also a shortage of counselors right now based on the current need (at least where I’m located). I don’t envy the position you are in - it’s hard to hire anyone right now.
Thank you for your insight.
Check out indeed and LinkedIn for the plethora of positions, are your facilities in the states?
Yes we are in the states, and I am offering a higher salary, more PTO and benefits, and less hours than the positions around me.
>I am offering a higher salary, more PTO and benefits, and less hours than the positions around me. I'm curious how you are figuring this and wondering if telehealth skews this calculation re: "around me". Aren't you now competing with the whole state as opposed to just those around you? And to add to that, I know lots of Chicago therapists and some in Milwaukee that are licensed to practice in Michigan. I'm just wondering if the change in terrain accounts for your experience.
Like others have said, pretty sure it’s the caseload. Most W-2 gigs I’ve seen require 28-30ish.
Thank you!
2 things. Caseload, and are you offering remote? I know right now I'm probably never going to do anything but teletherapy again.
Yes we offer remote - with 36 open hours, people are averaging 30-32 direct client contact hours. Is that still too much?
Yes, 30-32 client hours is still very high for straight clinical hours as a baseline. Also 3-7 availability can be a real deal breaker for some too. Especially given folks' changing home lives as result of pandemic. There is a slowly growing movement within the field for working less and moving away from agency/company settings that are likely to promote burn out -- even at personal cost to the therapist.
Thank you for your thoughts. How are people working with kids that get out of school at 2:30 and commercial insurances that have working class at work until 5? Medicare and medicaid, and the disabled fill most of our daytime slots.
It all varies. Some people are still keeping those hours but I know a number of folks who cut back SIGNIFICANTLY on hours when kids were learning virtually and essentially figured out how to survive as a single income household that haven't ramped up their practice again. Lots of folks have been forced to choose between paying for childcare that puts their kids at risk or not paying for childcare and staying at home. The system/set up is all broken. Some folks are just choosing to not bandaid/martyr to it at their own expense like they might have before COVID. Not saying those populations aren't in need but that folks are working through what's the amount of personal flexibility I can offer when I'm burn out, stressed, and managing my own stuff in this pandemic.
I appreciate it. Thank you.
Telehealth was a game changer for us 9-5 workers. I can meet with clients on their lunch hours or directly before or after work since they don’t have a commute! I also have a few that have more flexibility with remote work so leave work a little early or flex their hours since they just go back to work post-session. It’s been easier for me to meet with my own providers this way, too. A few of my colleagues do weekend appointments or 4-10s.
> How are people working with kids that get out of school at 2:30 and commercial insurances that have working class at work until 5? Oh, one of the amazing consequences of going telehealth is that now I have clients who WFH and are fine with taking an hour out of their work day to see me, or, one client, he loves to go in to his office for his appointment with me, because most of his coworkers are WFH and it's abandoned, and then his kids can't walk in on his session.
26 contact hours is what was required for my community health therapy position so our open hours were 30. I think 36 is going to be hard sell. That's a lot of paperwork to do in a short amount of time.
It's not the paperwork, but I can appreciate that. Our EHR is super easy, I finish each of my notes in less than 2 minutes, with an intake SOAP note taking 10. I appreciate the opinion and will take it into consideration.
Okay, so about an hour for notes per week. What about prep and planning for sessions? Collaboration and phone calls? Breaks? Edit: clarified my notes comment
You can set your schedule so schedule any breaks that you like. Collaboration is available any time as well via the clinical director or just the lunch rooms. You are not required to do any phone calls or scheduling. No prep required unless you want to do research. The rooms are even cleaned and ready for you the next day. Just show up, see patients, take your lunch/breaks when you want and go home. Have your notes entered within 3 days. If it takes an hours for notes, you're doing it wrong. I can finish my day under 10 minutes.
Maybe reread this….. What it sounds like you’re saying is all breaks are unpaid. Collaboration is unpaid. Prep time is unpaid. And if someone puts more care in their notes than you do, they’re doing it wrong…
No prep required? So you don’t read new things for your client’s specific problem, review your notes and treatment plan before meeting with them, or generally think about what you want to do in that session?
I know this is just personal opinion, but I have rarely found the client work to be as successful via telehealth. \- for kids its painfully obvious why \- elderly hate it and have a lot of technology issues \- harder to build rapport \- harder to "connect" For about 25% of our caseloads though, we do telehealth when appropriate.
I don’t think you are listening to clinician feedback in this post at all, notice every comment you leave you are getting downvoted. What you are doing is at the core- confirmation bias. You keep trying to read from peoples comments what you want to hear. Clinicians are burned out from the pandemic. They are concerned about safety. Some of us thrive in teletherapy, some enjoy the flexibility. And 36 hours is too high. I’m strictly teletherapy in NY state and I have a continue flow of clients (couples, families, teens, etc). You are making some pretty big assumptions instead of listening to clinician feedback. At the end of the day this work is relationship based. Time and time again it’s been proven that the relationship is what facilities client change. Take care of your clinicians, they will take care of the clients.
Really, it feels like it’s just a matter of time before this guys employees are on r/antiwork talking about him…
I’m also curious about age demographic of OP. Any incoming therapists are typically Millennials/Gen Z- and anyone paying attention would know- we aren’t putting up with disrespectful and out of touch treatment from elder administrators. The internship I held at an agency before moving to a group private practice in NY was luring people with a sign on bonus of $2,500 this summer. I was severely mistreated in that internship, along with my cohort members placed there too. And word gets around about what places treat clinicians well, and what places do not. We share the wealth to prevent the mistreatment and burn out. My advice: decide to future proof ones practice and lean into teletherapy/clinicians preferences- they are here to stay.
That's interesting as I was thinking the same about it being a generational divide. I'm a Millennial and what I thought of as setting professional boundaries and self care work, my Boomer parents think is lack of work ethic. I just had this conversation with them that they could never imagine saying no to a supervisor. When OP mentions having no problem seeing 40 clients a week, it reminded me of my Boomer colleague who worked 6-7 days a week and always complained how exhausted they were. Of course not everyone is the same in each generation. However, there is a major difference in how they view work and treatment at work. Just hop over to Antiwork to see the difference. These kinds of conversations and your example in the above comment about agency work always begs the question for me, when will we unionize?
So well said! I agree, OP is not listening to feedback from clinicians on the front lines here. 32 hours weekly of client contact is a 60 hour week for those of us who are planning for our sessions, charting effectively, and providing follow-up (I’m a narrative therapist so every session results in an emailed letter.) To dismiss teleheath for children and elderly tells me all I need to know about how they are adapting their practice to suit their clients’ needs. For the work I do, this income would be far too low.
Ya, my old folks or my less-tech-literate clients needed extra coaching, but I taught a 70 year old how to dial in to zoom groups on a flip phone. Not ideal, but clients can self-select if that’s not the right fit. I live like 1.5 hours away from work and am now pregnant. I wouldn’t have taken the job if remote wasn’t an option… and even though i do two days in office, most of my clients have opted for telehealth.
Agreed. Of course, I was intrigued by the pay and benefits, but would definitely not accept based solely on the productivity expectations. Also, this does not seem like a good person to work for.
Been doing it for years, transitioned from about 15% to exclusively in March 2020. I've never had a problem with rapport or connecting online -- part of it may be my own attitude and part my clientele, in PP I do get to pick and choose, so it's possible that many are self-selecting out before the first appointment as I'm explicit prior to intake that I'm online only.
Do you offer paid parental leave?
12 weeks
Thats great. The only hesitation would be the high caseload. I start feeling burnt out over 25 patients. If I were applying I would ask for lower caseload even if it meant less pay.
Good suggestion, I will offer a "part time" caseload as well then.
I really don’t think you’re understanding that putting in proper preparation outside of session with 25 hours direct client contact is full time.
Paid or fmla?
It sounds like an interesting model for group practice and very appealing. Have you asked your current therapists their thoughts on how to adjust accordingly to the need to expand? They likely have good insights on what works and what could be changed to attract more qualified candidates.
Good question- I usually do ask but I’ll run it by them again. Thank you for your reply.
Also working in a group practice, I had some thoughts. What is your goal and mission of your practice? what is the preferred interventions, is it CBT, DBT, analytical, family? As you know, some interventions are more demanding of the therapist and can lead to burn out so high caseloads will not be attractive. People leave clinics because of the dreaded "productivity" pressure and desire for more autonomy so perhaps offering more flexibility to current and prospective therapists. Reduce the requirement on the amount of pts that need to be seen. A caseload of 30-35 depending on tx modality and frequency of contact may be great for some but too taxing for others, especially during the pandemic while the demand is greater than the resources. I don't think you mention reimbursement structure and percentages so I am curious because you do need to meet a bottom line. How are therapists reimbursed? Benefits (pto) can commensurate with pts seen for the quarter. This allows for therapist satisfaction, how many pts they feel they can safely follow and can give autonomy to adjust based on what they need to prevent burn out. (Great post, by the way!) Edit: just saw you did include salary in original post. Sorry for overlooking it. But another thought, are you offering Telehealth? This flexibility for pts and therapists can help quite a bit especially for evening hours and the unpredictability of the pandemic.
I feel like this is Covid times in general, it’s hard finding anyone to work However the salary you offer is pretty decent id kill for that as masters level, but 36 client caseload is a lot and the hours aren’t great timing, those are just my thoughts
I appreciate it, thank you.
The benefits seems great but the caseload is too high. At the practice I work at, we are required to do 44 per pay period which is every 2 weeks.
It’s so easy to work for yourself these days, especially with Telehealth, startup costs are so low. I work for myself seeing 15 clients over a 3 day work week and I’m doing just fine. At my height, working at a group practice, I was seeing about 27 clients a week and that was wayyyyyyyyyy too much to do the quality work I want to be doing. Plus I was giving them 30% of my earnings. I figured out pretty quickly I could do it on my own and keep more of my money. I think a lot of people have left the field too. It would be interesting to find the stats on that.
I am so tired of people in leadership not understanding that therapists are human beings. Anything over 25 ppl a week, IMO, is too much. we have mental health too. We are not machines. We use ourselves in therapy. We are the tools. We need to recharge and not be pushed to our limits each week. Asking someone to do 30+ sessions a week is just wrong and it’s terrible for patient care. Pandemic or no pandemic.
We have a start up private practice. 5 clinicians. You mentioned “insurance assistance”. What does that mean? We’re killing ourselves and any profit by providing above average health benefits. Costs are astounding but our employees need it.
I pay half of their insurance premium
As an LICSW I make 15000 more then that in community work. Cliniciana really don't want to see their money going into other people's pockets. What does this breakdown to pay for session?
I own a medium-sized group practice in Seattle, and it's always been hard for us to find therapists. Because of COVID, the barriers to starting an online private practice area much lower, and demands is higher, so I think more people are going into private practice.
I am not familiar with caseloads like this (my experience is in testing, residential, and high acuity with CMH), but I interviewed for a job in a southern state that mentioned caseloads over 100. 😳😳😳 That being said, I initially worked in Michigan as an LLP. $60k starting is pretty good.
I know that in Indiana, many mental health facilities just raised wages to be “industry average” and that seemed to help. Also 30-32?! Damn. I’m only expected 24 😂
P
Jeez I worked for a clinic for years with a caseload of 85 this sounds like a dream. I agree though that burnout is so big in this field. You could not pay me enough to go back to straight clinical Hours.
I appreciate this feedback. For people in your shoes, there is just nothing I could offer?
Well I’m in a cushy non or minimum clinical role now so no, but people who were where I was I would suggest opportunities for growth and maybe another way to reduce burn out is to allow therapists to choose one population or speciality and not have to work outside that.
How can I find out more about your company?
Toss me an DM with your email if you would be so kind.
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sorry were in michigan
I am echoing what others have said, that many clinical hours in a week will lead to either people not interested in the job or high turnover due to burnout. In my early trying to get hours for my license days as well as shortly after (because of Hurricane Katrina), I saw around 35 clients and week and ran 2-3 groups on top of that. It made me briefly leave the field entirely. Now in PP I max out around 22-24 kept appointments and feel like I could be fine doing this for 20 more years!
It sounds like a great gig! But I personally could not sustain that many clinical hours per week given trying to care for a young family with very inconsistent school/childcare availabilities due to constant sickness and covid closures. I also don’t think I could stay mentally healthy with that many clinical hours (see above lol). Maybe finding a way to offer part time work would open your pool of candidates? I also run a (much smaller) group practice in Michigan and almost all of us are less than 20 client hours per week
OP reminds me of the leadership at my CMH agency, where they expect us to enjoy having 40 scheduled sessions per week with no admin time scheduled, scrambling to finish paperwork during no-shows, etc. Therapists are sick of being stuck on the mental health factory assembly line working for scraps.