Episode #110

The number of therapists in private practice is going up. When I started in the field, private practice was something you did later in your career. The changes in the landscape of agency work is changing that though. Rising productivity, less time for paperwork, low levels of support and low pay rates are driving more therapists into private practice (or into changing careers). We are going to be talking about the issues facing therapists and the need for private practice to be skilled in doing substance use work.


You’re listening to the All Things Substance podcast, the place for therapists to hear about substance use from a mental health perspective.  I’m your host, Betsy Byler and I’m a licensed therapist, clinical supervisor, and a substance abuse counselor.  It is my mission to help my fellow therapists gain the skills and competence needed to add substance use to their scope of practice.   So join me each week as we talk about All Things Substance.

 Welcome back to the All Things Substance podcast. This is episode 110. This is the first private practice episode that we’re gonna be doing. For those who didn’t hear about it yet, let me explain. About a year ago, I did a student edition episode. That was born out of a number of comments that I was seeing on Facebook that were popping up all the time.

A lot of students join our therapist Facebook groups asking questions about becoming a therapist, about schools, about licensing. We know that there’s a lot of information that would’ve been helpful for us to have before we went to school or even during. And so what I did was create a podcast series that would answer those questions.

I wrapped up that series last year and just continued on with the plans that I had  for the rest of the podcasts. Well, what I have noticed over the last year is this ongoing conversation about agency work and private practice, and I wanna be able to address some of those things. 

Some of the topics we’re gonna be covering are why for profit and not make a non-profit, taking insurance and the idea of being a private pay therapist. I am talking about these things in the hopes of opening the conversation and sharing some perspective after almost 20 years in the field and watching the changes that are heading for. 

For myself, I wanna start at the beginning. I wanna be honest about the opinions that I had when I was a wee baby therapist and before I really understood what the landscape of doing this work is like. I never planned on going into private practice.

It used to be that when you went to graduate school, the next step would be, of course, getting a job. It was pretty much expected that everybody’s gonna go into an agency and work in an agency for the majority of their career. The idea was that later in your career you would go into private practice when you felt like you wanted to limit your cases and you wanted to maybe work part time. It wasn’t the majority of therapists at all that were going into private practice 

For many years I had Capital O opinions about private practice, and those have changed dramatically. I still believe that new clinicians probably need agency experience. They need supervision. For all of you, students and people heading out into the field, please make sure that you get supervision as a part of your job that it’s paid for and by the right person. 

If you are an LMFT, you need an LMFT.  If you are an LPC, make sure you get an LPC. Same thing for LCSW. All over. Please make sure that you make that part of it.  It is a negotiating piece, but it is so important that you get the hours that you need without having to pay for it. 

I do believe that new clinicians need to get some understanding of how the agency flows and how things go while still making money, even if people don’t show up. So I do believe it’s worth doing agency work. I would encourage you that if a place has a bad reputation and really high turnover, keep on looking. I think doing some time in an agency is important, but I do believe that people are gonna start moving into private practice sooner than I would’ve ever thought.

I would encourage those people as well, who are newer clinicians going into private practice to get a coach and how to build them and to make sure you’re paying for consultation for yourself, even if you don’t need it for supervision. Clinical stuff comes up all the time and your colleagues who are also in private practice won’t really have the time to devote to helping you with it.

Consultation is a cost and it is an excellent way to learn. I’ve been doing this for almost 20 years, and I’m in a consultation group once a month with other EMDR therapists. I find it super useful.

With the trend changing. There are a number of topics that came to mind that I wanted to comment on. Those range from. Non-profit status to a for-profit agency, to group practice, to private pay clients, to insurance, to online therapy, and managing risk. You’re going to hear me say a number of times  in the coming episodes that if you have spots available in your practice and you are willing, there are clients for you.

There are clients who have problematic use. And who need outpatient therapy. They don’t need to go to a substance use treatment center. I can teach you how to quickly assess whether they’re appropriate for outpatient mental health and once they are in your practice, I can teach you what you need to know to help them through this issue.

 You don’t need a new modality. You don’t need a certification. You already have the skills you need, and so if you are willing and have spots, there are people who need you.

I encourage you to consider adding substance use to your scope of practice. Putting that  out, in the list of things you’re willing to treat. I believe that you will get clients and fill the spots that you will, that those people will find you, and that you will be able to fill the spots that you have available and continue doing the good work that you. It can be scary to step into a new thing, and I will be with you all along the way.

For many years I had  opinions about private practice, and those have changed dramatically. I felt like private practice was for people who wanted to work with the working well, so to speak. People who were highly functional and just struggling a little bit here and there. I wanted to work with underserved populations and I wanted to work with people who had significant trauma and struggles in their lives.

I naively felt like that couldn’t be done in private practice, and I had that opinion for kind of a long time. In my career. I did in-home therapy, I worked in residential, both short term and long term and then moved into outpatient work. I’ve been in community mental health most of my career.

I felt good about the work we were doing and the people we were serving. I became a supervisor at age 31, which was pretty early for being a supervisor. This isn’t, because somebody came to me and was like, Betsy, you’re amazing. We want you to be the supervisor. This was when a position opened. I’d been with the agency for four months and nobody was applying. 

One of my friends came to me and told me I should apply, and I was like, uh, no, I don’t wanna be in charge. I knew that someday I would end up in leadership because that’s my personality, but I in no way felt qualified or wanted that kind of responsibility. I was becoming an outpatient therapist. That’s what I wanted to do. 

I had built a full schedule in four months and was seeing. I think I had 104 open clients. And then he said, the thing that would make me apply, he said, yeah, but what if you get a boss that’s an asshole. Wouldn’t you rather be the boss? And I was like, fuck yes, yes. I would much rather be the boss. And so I applied and I got the job. 

What began then was my development into being a supervisor and then a director. I didn’t realize how good I had it in the agency. And it’s not so much that the agency was perfect because it wasn’t, but I had an incredible amount of autonomy for a number of very specific reasons, and therefore I was able to create something really special.

When I took the job, my mom, who had been an officer in the Navy said to me, okay, Elizabeth, here’s the thing you need to remember. Loyalty up and loyalty down. I was like, okay, what? And she said, “you are in the middle. You are loyal to the brass, meaning those above me. And you are loyal to your people, the people underneath you. And nobody gets to your staff except through you.

And nobody gets to management except through you. You are the conduit. And that statement formed the way that I supervised. I was able to create a team that knew beyond a shadow of a doubt that I would stand up for them, that I stood between them and anyone else. Nobody from management talked to my staff without talking to me first. I handled the problems that my staff had when I needed to go to management on their behalf and I was able to create the team that felt like home.

I did supervision often. Part of that was having supervision even for licensed people. Unlicensed people or pre-licensed people, had supervision every week individually and group supervision. In some cases, they even had more because they needed a different level of supervision from an LMFT or from an LCSW.

I made sure that they had time for paperwork in their schedule. I made sure that they were happy with what it was they were doing, and the clients they were seeing. When they brought me problems, we solved them or did everything we could to make adjustments to make it easier. Fully licensed people had supervision every other week.

When I would ask them if they wanted to drop it down to once a month, the answer was no. They did not want that. And so as my team grew, my supervision time grew. I think the reason I was allowed to do that was because our no-show cancel rate was really low.

In community mental health the no-show cancel rate is a problem. Showing up to appointments consistently and on time is a privilege. It is something that is afforded to the middle class a lot of times and it’s not about worth, value, respect or any of the things that people assume. 

It’s because when people are doing okay financially, they can prioritize. They can make choices about how they show up for things. They can decide that they’re not gonna be rushed or that they’re gonna reschedule. They aren’t thinking about survival, and so they have more brain space to plan. When folks are struggling, which is our population, that is a problem. 

What we had to do was be creative. That was when we started doing therapy in the schools. That ended up with therapists needing to help manage their own schedules so that they could have conversations with their own clients. We had good productivity knowing as I look back later, that was part of the reason we got left alone. Our paperwork was also done on time.


I also remember going through 13,000 lines of data in an Excel spreadsheet to find out why we were having claims fail. I narrowed it down to eight different points of failure, including credentialing, scheduling, diagnosis codes, and worked to fix every single one of them. I had a lot of power and autonomy because I was fixing problems that managed revenue.

That wasn’t what I was after. I wanted a team that felt supported and cared for, and as a result, they were loyal. And loyal to the point that they followed me from one agency to another. I was extremely blessed with excellent clinicians and really solid good people. When we changed agencies, though, I realized what I had that wasn’t going to be able to exist in the new place.

Not every CEO was willing to let me have the autonomy to run my program. Not because I was doing anything wrong, but because that wasn’t how they rolled. It caused a lot of conflict and I did my best to shield my staff from it. It was difficult and ultimately a number of things came to be, and me and the majority of my staff have scattered to the winds. I ended up going into private practice because of those events in fall of 2019. I had never considered going into private practice at that stage in my career. 

I had spent over a decade in the area,  integrating myself into the fabric of the community. Being someone who was an expert in the area of mental health and substance use, and founding and chairing a coalition, being on other coalitions, helping develop programs with the police department, lobbying at the state level, and doing all sorts of things here in our small area.

It was really weird to back out of all of that.  Now that I’ve had the chance to be out of that world, and watching and listening to how other people are talking about their agency experiences, I realize what a bubble I’ve been in. Every day in our groups on Facebook, there are people talking about productivity expectations, low pay, burnout, overwhelm, and I think about, well, why aren’t there supervisors doing better?

Why aren’t they doing more? And I realize that potentially the reason is they can’t. That they’re in a system that refuses to allow them to do what they need to do for their staff. It is possible that people have bad supervisors, but more likely than not, they have experiences where they can’t do the things that they know how to do. And that the supervisors are experiencing things on the back end that they can’t talk about. 

It’s very hard to be a supervisor or a manager. It’s like being on the end of a tree branch with everyone else back at the trunk, and they’re making statements about what they think you should do out there. But they’re not the ones out there and the one who’s at the end of that tree branch usually can’t talk about what’s happening out there. It’s very challenging and very isolating. 

It wasn’t until moving into private practice and even more so getting into contact with other therapists in different places that I found I was able to have therapist friends. I love my staff, and when you’ve been someone’s boss, it’s kind of like it stays there whether I want it to or not.

What that brings me to is that I have changed my opinion about private practice dramatically, and to a really extensive degree. I no longer can see that most therapists will do agency work for their careers. I see that agencies are becoming more and more unsafe for people. 

What hit the medical community is now hitting us. Shorter visit times are being pushed. Overbooking, double booking. No time for paperwork, no time for staff development or supervision. I have a physician friend who calls it moral injury. That she was unable to give her patients the care that they needed because there was so much more to do and more clients to see. Doing paperwork at home, working on weekends, all sorts of things that were happening that can’t be stopped, that don’t allow us to do our jobs.

The day that I had someone suggest to me that we double book therapy appointments, I remember my brain skidding to a stop, like cartoon style, right? And I was like, what the fuck? It was so asinine. I didn’t even know how to respond. And the person who said it was like, half kidding, but not. They really truly had an answer when I said, what if both people show up?

And their answer was, well, they could each have half the appointment. To which I said, would you be okay with that or is this just for poor people that you wanna do this? We are committed to quality care for everyone regardless of their status in whether they’re paying or whether it’s Medicaid or whether it’s full fee private pay.

Everybody deserves good care. Now, I happen to believe that medical care is a universal right. I also know that the system is what it is. Private practice is amazing. I literally had no idea. It’s not that hard. There are things about it that are hard, but it’s not impossible. You make more money and it really is something that I think can be done well.

I think that it is going to be a large part of the future of our field. Because the thing I know is that once people can squeeze more visits out of a team, they’re not gonna go backwards. The agency doesn’t need less money. No one’s coming along to give agencies more money and so this trend is gonna continue.

It is difficult for me to watch it happen because I truly believe in what we do and especially those of us who are working with really heavy cases and trauma. I think we also need more space and we need more support and supervision. And not supervision in the sense of keeping an eye on people, but support.

There were plenty of times where my staff may not have had a case to discuss, but they didn’t wanna cancel. They wanted the time. They wanted to sit in my office on my couch and just have me a hundred percent focused on them and be with them. And that’s what we did and it made a huge difference. 

As I watch this conversation happening, I see the need for information about private practice. There are a lot of folks online who help people develop private practice. I’m friends with a number of them. There are other folks who help people scale their private practice, and there are other folks who help people attract private pay clients. 

I had a chance to sit down with one of my friends who does this work. She helps people develop an online private practice and helps people market to private pay clients. I used to have opinions as well about private pay clients until I understood what reimbursement rates were like for different insurances in different states. For instance, there are places where the Medicaid reimbursement rate is $60 an hour.

If you were getting paid $60 an hour at your agency every hour, that would be amazing. But $60 an hour when you’re in private practice is nearly half what you need in order to make the amount of money that you need to live. I know that sounds ridiculous, but the way it works out with the number of clients you see in a week, and taxes, not to mention doing things in an office, having a group practice. That’s not that much. 

In fact, that’s nothing at all that is not a sustainable wage, even though it sounds like a fucked ton of money. I didn’t understand why a therapist would go private pay instead of insurance. I had to talk to a couple therapist friends who live in other states, and they would tell me about their insurances. They would tell me about the problems getting credentialed. They’re in places where there are too many therapists and certain insurances won’t even take them anymore. 

It is an incredible challenge and there are so many nuances here. So as we move into the private practice edition, we’re gonna be talking about some very difficult things, and I’m gonna be talking about them in a very blunt way.

If agencies are not the future of our work, then private practice needs to be the place where people who are struggling with their substance use can find help.

The message that I have for you is that if you are willing, there are people who need you. If you have spots available, there is a need that is not being met by the therapists that are out there now. There are clients who need help with their problematic use. I can teach you how to do it in a way that fits with your style, that doesn’t require a certification, that doesn’t require going back to school or a specialty.

We’re gonna talk about a number of different issues in the coming months, and I wanted to bring this up and introduce it to you today so that you know where we’re headed, and knowing that when you see the private practice edition,  we’re gonna be talking about some of those topics.

Next week I have the privilege of sharing with you a conversation between myself and Dr.

Amber Lyda. Amber is a psychologist from Florida who built a successful  online private practice before Covid, and has spent the last several years teaching other therapists to do the same and to do so in a way that goes along with the way they wanna practice and their values. I wanted to talk with her about the idea of substance use being part of outpatient. That conversation’s gonna happen next week, and  I hope you’ll join me for that podcast. And until then, have a great week. 

This podcast is designed to provide accurate and authoritative information in regards to the subject matter covered. It is given with the understanding that neither the host, the publisher or the guests are rendering legal, clinical or any other professional information.

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