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Explainer for when someone complains therapists don’t have poverty cred.
I grew up in deep poverty — “skip before eviction” & “random utility cuts” type. I was only in the same school for 2 years twice. And never in the same school/house for +2 until uni.
1/
There *aren’t* many therapists with deep experience of poverty.
I was strongly encouraged to change my course of study.
If I hadn’t been 100% undergrad scholarship & 95% funded in grad school, I would have changed majors, because I could not have afforded to be a therapist.
2/
There are two forms of therapists: Psychologists (‘ologist hereafter) and psychiatrists (‘iatrists).

‘iatrists go to medical school, they have hardware & chemicals certification; they can prescribe; it takes ~10 years, they graduate with a minimum of $150K of debt.

3/
‘Ologists need a minimum of 7 years of education, very focused on the software side of the brain, behavior & mental health; they can practice with a master’s. $60K in debt is about median.

Psych refers to the whole field, both sides of the house.
4/
I’m an ‘ologist because I couldn’t afford med school.

I needed to be self-supporting ASAP because my gambling addict & my compulsive shopper had less than nothing to offer. (They stole my identity before I was 18.)

5/
Let me explain psych before ACA & the mental health parity law, because anyone who is
1) still practicing &
2) went directly from HS to college to grad school to practice&
3) is at least 32?
This is what they graduated into.
And why poverty weeded poor people out of psych.

6/
Psychiatrists did their residency and worked as hospitalists the same way most doctors do — residency paid (poorly); hospitals paid slightly better; communities recruited doctors with subsidies for loans. (Go watch Northern Exposure for a comedic version.)
They did ok.

7/
Psychologists had two paths: public mental health, or private practice.

Public mental health is where almost all of us started, usually right after we got our certification. It was a guaranteed job, but it never paid well.

(We’ll cover private practice later.)

8/
My first year in practice? I got paid less than a first year elementary teacher with a bachelors & a teaching certificate. ($27K vs $31K in the district I lived in.)

(We both made 50% of what a rookie cop with a 12 week certificate made. And took more abuse.)

9/
Public mental health is paid for by the county and/or state, usually as a hybrid of Medicaid & the judicial system.

In no place in the US has this EVER been fully funded.

Before parity? Not remotely close.
I was lucky. I was an employee.
Many counties want contractors only.
10/
There was no communication from the courts to the mental health system. (We had reporting requirements.)
Judges sentenced people to mandatory therapy as a condition of probation or diversion, and never counted how many they referred.
The county never funded extra therapists.

11/
A therapist should have MAX 35 hours per week for appointments.

This assumes someone else answers the phone, schedules appointments, transcribes notes, files, pays the bills, vacuums, etc.

Every hour of infrastructure work is one not available for therapy.

12/
And HELL YES, we get 2/3rds of the week to NOT BE THERAPISTS.

Therapy is HEAVY emotional labor every single day for people who cannot (and should not!) reciprocate.

We do not do this for free because we CAN’T.
We would burn out and then then there’d be no therapists.
13/
Therapists who burn out & stay in the job become callous & careless.
Sadists unfortunately thrive in the dysfunctional environment of PMH.

About 75% of new therapists were not practicing 5 years after graduation — they were exploited until they had nothing left.
14/
Given 35 hours a week, a client roster should max around 100 — that means you have 1 therapy hour every 3 weeks for each client, with about 5 emergency hours.

(I’d like to get us down to 60. For this to happen, we need way more therapists, and we have to pay them.)

15/
In the Public Mental Health system I worked in?

I started with 300 clients assigned to me in the first 60 days, and hit 400 by the end of the year.

Only about 10% of my clients were volunteers; the rest were court mandated (probation/diversion, or family courts).

16/
You can extend your working hours with group therapy & phone checks instead of appointments, but not as much as anyone needs.

And in PMH, it’s almost guaranteed that your clients are just as poor as you are — and they don’t want to be in the chair.
17/
Often, their therapy requirement imperiled their ability to pay the rent or keep their kids in shoes and food. So they had very, very good reasons for resenting the hour that the justice system demanded & nothing more available after showing up.
And I don’t blame them.

18/
(I note that $27K was just above the limit for public service loan forgiveness. May every republican to have existed since Abraham Lincoln go fuck himself. But especially the ones in the 1990s House of Reps. Pieces of ambulatory feces, every fucking one.)
19/
Every therapist I worked with either had a partner mostly supporting them — AND THIS IS BAD BECAUSE IT ENABLES DOMESTIC VIOLENCE — or qualified for TANF if they had a child, or were on food stamps.

Or had wealthy parents.
20/
So... burnout? Yes, burnout.
(On this, little has changed. I believe in online therapy, but part of the reason it’s exploded recently is because it allows therapists to make extra money. It’s a side hustle, which means working many hours beyond 35. It courts burnout.)
21/
And here’s the thing: psychologists are not social workers.

We know very well that 90+% of situational anxiety & depression are too much month, not enough money. Most of us know that trench well.

But we also know that the only exit is to do the therapy work.
22/
Because we also know the social workers are MORE overworked & the social safety net is crap.
We know it sucks that the only thing we can offer is wanting behavioral change, lest your situation grow impossibly worse.
We try to keep you from what happens when it gets worse.
23/
If you lack the spoons to do your therapy homework?
You will have even fewer spoons when your marriage fails and you have to pay two rents on the same incomes.
Or your housemate moves out because they can’t take your anger.
Or you’re paying restitution for breaking someone.

24/
We’re not allowed to yell this at our clients, and it wouldn’t help anyway.
Yelling never helps.

But I was raised in abuse.
I know that before we do the work of therapy, most people underestimate the direness of a situation if someone is soft-spoken and not issuing orders.

25/
A therapist can’t create money or time. All we can do is help build a toolset to reduce the chaos (which becomes more money/time. Eventually.).

But if you feel therapists dismiss your situation since they’re asking you to work on you? That’s... toxic entitlement.

26/
It’s excusing yourself from fixing your thinking & behavior, and allows you to blame all of your externalities instead of practicing control of the one person you have control over.
It’s thinking you’re so special you don’t have to work on your part of the social contract.
27/
Yes, PLEASE blame capitalism — I do. And Republicans. I sure do. And Calvinism and puritanical culture and an entire world whose perspective ends 20 feet past their nose.

But in the moment you’re in therapy? That’s not your job. Your job is you, learning to be prosocial.
28/
(This is an end goal of therapy — eventually, your therapy homework is “go help pull people out of the hole you used to be in,” then, “go fix the hole.”

But you can’t do that while you’re in the hole, and all therapists can do is help you build your unique toolset.)
29/
You know what else therapists can’t do?
We’re not supposed to tell you what to do.
We’re not supposed to give advice.
(I can do that *here* because none of you are clients.)
We can guide you to YOUR conclusions, but beyond that is enmeshment, and that devastates a client.

30/
This is why a lot of therapy fails — the client WANTS to outsource their decision making.
And we cannot take that on. It’s BAD for you.
Only you can captain your life.

TBH: when we’re honest & remind a client about this part of the contract? They usually flounce out.
31/
Which is their right.
(We get real good with radical agency. Everyone has the right to their own decisions, even bad decisions.)
We can’t force anyone to do the work.
But seriously: the work of therapy is free. It’s almost all internal. Pen & paper are the most likely costs.
32/
(PS: Beyond cost of service, a therapist shouldn’t ask you buy anything but a notebook/inexpensive app. Some may recommend books; it shouldn’t be their own.)
(Pro tip: when you walk into an office, walk out again if they sell supplements or a program. Big ethical red flag.)
33/
(Your GP doesn’t sell medicine - they send you to the pharmacy. This is an intentional division of labor to prevent conflicts of interest.

Therapists have the same requirements. And especially avoid therapists who sell MLM products or unregulated supplements.)

34/
Therapists TRY to keep therapy homework at 5th grade level (30 minutes a day, can be broken into 10 minute segments) instead of college midterms level.
We know your time & spoons are limited.
But we also know that the reason you’re in therapy is to prevent the worst outcome.

35/
You wouldn’t be in the office/chat/on the phone if everything was great.
You know there’s a problem.
You know it needs to be fixed.
So yeah, we expect you to prioritize the homework, because you have an emergency.
But it’s a slow emergency, so people get impatient and bored.
36/
This part of human nature? Doesn’t change without effort & attention. Ancient Greeks & pre-modern monks & early Freudians & mid-century behaviorists all took note of this tendency.

And it becomes a vicious cycle that VERY specifically means mental health is underfunded.
37/
Part of the reason public mental health was so badly funded until 2013 was because there was no legal requirement that any insurance cover any mental or behavioral health care, and when it was covered, it was extremely limited, and badly reimbursed.

38/
Since there was no requirement to pay for it, the insurance companies almost never saw an *actuarial* benefit to therapy, which made them less willing to pay for it, which meant less access— See where I’m going?

Though clients in the public system usually didn’t have it.

39/
People with private insurance/money who were court ordered into therapy went to private practice.
(This is an improvement — with the parity law, public can bill private insurance & it gets covered, eventually.)

There was _no_ route for me into private practice then.

40/
There were 2.5 routes into private practice:
1) set up your own small biz. This requires credit, navigating the Small Biz Admin, hiring support staff, office rent. Expect $200K in startup costs.
2) Buy into an established practice. Also $200K.
2.5) get hired by ☝️as locum.
41/
But to get to 2.5, you needed several years of experience, usually only available through... public mental health work, or connections. Or both.
(I told you, poor kids majoring in psych were encouraged to find another way to make a living.)

Why??

42/
Because the insurance companies were worse then than they are now. And that’s saying something.

All therapists were treated as specialists. That meant the copay was high, which was a limiting factor right there.

People choose a week of groceries over therapy every time.

43/
Now, let’s compare to regular doctors.

Back in the early naughts, a non-partner GP/pediatrician (so an employee, a locum) in a general/family medical practice earned about $75K a year, and often had a portion of their student loans covered. (Often true for PA/NPs, too.)

44/
A GP/Pede/NP/PA in a regular practice usually has 10-15 appointments a day (about 30 minutes ea), and they usually see any given client about 4 times a year. That means a GP’s max client roster is around 800 people, not 100.

45/
In a GP practice, most of the time, the 5-15 docs & PAs back each other up.
Most people are perfectly fine seeing Dr Smith or PA Jones for their bronchitis, while that’s simply not true for psych.
And insurance reimbursed GPs at a much higher rate, and much more quickly.
46/
The cost of doing business as a therapist with an office bottoms out around $300 an hour. You can reduce it a little if you go to your clients/have a home office/use an answering service instead of a receptionist (and now, billing collectives)... but not much.

47/
In the bad old days, the median copay for a therapy appt was $60. That kept the rent paid, the lights on, and someone answering the phones.

It did not repay loans or pay the therapist, and it certainly didn’t pay for the insurance clerk, or malpractice insurance.

48/
The insurance clerk was a necessity, because private insurance were JERKS.

So, the GP practice above? They got paid about $80-$150 per visit, and insurance paid them pretty quick.

By law, insurance must pay within 90 days, but GPs usually run 60 days.

49/
By law, insurance must pay therapists within 90 days, too... but it was usually at least 120 days. 180 wasn’t uncommon. Or they’d hold payment until around 150 days, then reject the claim, so in reality, it could take 10 months to NOT get paid.

For each appointment.

50/
That’s why a private practice ran $200K in startup costs for the first year. Insurance rejected 25-50% of claims.
They knew we couldn’t afford to sue.

(BTW: they’re doing it again. Blaming it on COVID and the insurance regulators are letting them get away with it.)

51/
Poor kids with $60K in student loans, who couldn’t tap into 4 generations of equity and savings? It simply didn’t happen.

(And this is why I’m a Single Provider (NHS) advocate, not Universal Insurance. Make us all employees. Insurance cannot be trusted.)

52/
So let’s do the math: a therapist took home ~$25/hr on that $300/hr cost. The rest covered self-employment taxes, employer taxes, salary for employee, rent/utilities, continuing education, and health & malpractice insurances.
That’s ~$54K a year, or $43K take home.

53/
$1680 a paycheck, assuming 26 paychecks a year.

It’s not the worst living, but for someone with a master’s degree? It’s low.

And in this case? Having a doctorate (and the cost of the doctorate) neither guaranteed better reimbursement nor made more hours available.

54/
(This was horrifically precarious — going bankrupt was just a thing.
Also why so many therapists simply did not take insurance.)

(Also why hiring locum therapists & paying them $12/hour and pocketing the rest was a common senior partner tactic.)
(Money & medicine don’t mix.)
55/
(Is anyone surprised this system can create really horrible, sadistic therapists? Is anyone surprised so many burnt out and ended up becoming HR managers or learning to be DBAs or software developers? Or that psych has an incredibly high suicide rate?)

56/
(Online therapy was exploding (before Covid hit) mostly BECAUSE it doesn’t take insurance. It’s real money coming into a bank account on a regular schedule. It’s the available freelance work.)
57/
Our culture treats therapy like it should be pastoral care — free — and treats therapists like ministers - poverty expected.
Except ministers do get paid & often have housing covered.
(And they can money launder on the side if it gets dire.)
(That’s mostly snark.)
(Not all.)

58/
Which is not to say religious therapy is a solution: religious therapy produce some really awful outcomes.
(See: conversion therapy. See: marriage counseling that denies divorce. See: spiritual abuse. See: Victim blaming, forced reconciliation with abusers...)
59/
We made therapy professional, without making it functional, so when combined with the human tendency to avoid the work of therapy (also true for physical therapists — humans tend to avoid doing their chores)
... we get insurance disinclined to pay for it.
60/
Therapy — behavioral, physical, occupational — takes longer to work than other medical treatments.
But long term? It’s cheaper than surgery or inpatient care.

Before 2013 (& now)?
Insurance companies operate on a 1 year model. They have to be forced into preventative care.
61/
It all comes down to ROI - the preventative care you get this year benefits the insurer you’ll have in 5 years, not the one paying now.

This system is built to fail — therapists, clients, justice, children, everyone. Because failure is more profitable.

62/
So, how do we fix it?

Well, how we approach and use therapy is the place we all have to start, because almost of us first encounter therapy as users, long before we become policy advocates.

Therapy is work.
I’m sorry.
We wish it was magic, too.
It’s not.

63/
Humans in general are not great at personal confrontation with ourselves, because most of our brains make us the heroes of our story.
When we confront our errors in thinking, we are also confronting the reality that we’re not perfect heroes.

64/
And before we start doing therapy work?

Believing in our heroic nature and the perfection of our perspective is one of our strongest self-protective constructions.
Or more simply: We need to believe we’re excellent just as we are to keep going.

65/
One of the first, and most difficult insights we get — often the one that drives us into therapy — is we’re not the person we thought we were, not the one we want to be.
Yes, it’s a crisis level hurt.
MANY, MANY, MANY people avoid this thought for YEARS.
But it’s also okay.

66/
We have to love ourselves, because we’re the only ones who HAVE to live with us, but we need to meet ourselves where we are.

And that means accepting that humans are imperfect bags of meat.
And being defensive, even with ourselves, is a useless waste of the only time we get.
67/
And if you’re not there yet?
If you’re still defending harmful behaviors, externalizing issues, refusing to dig in?

Therapy might work. Eventually.

It’ll take longer. A lot longer.

And you will be very frustrated the whole time.

68/
Structurally, what’s changed since 2013?
Well — therapists get paid, on a more regular schedule. Starting salaries are rising a little.
Payday isn’t only after the insurance company makes the quarterly dividend (which is legally required of corps).

69/
Therapists are more likely to get hired as employees instead of having to dig out a quarter million in financing.
Therapists are more likely to have health insurance themselves!
They’re less likely to bring clients into a home office.
(You see why this is dangerous, right?)
70/
Clients have more access to therapy.

Insurance companies continue to be slow payers, but because therapists are more likely to be employees, the business/office manager gets to fight with the insurance (and the bank).

71/
While psychiatrists are still mostly scrip pads (especially in public mental health), they can also be specialists who fine-tune scrips for clients having issues with the easy meds.

And it’s now a lot easier for psychologists to work WITH our clients’ GPs and psychiatrists.

72/
Before we all started getting paid like professionals, it was really hard to schedule consultations — there was no way to get paid for that work. Now it both matters less (shared records) and we have ways of billing for it. This matters for quality & continuity of care. 73/
And where do we go from here?

1st, we have to protect & expand ACA. Period. Right now, therapy hours are down in general because unemployment means less access to health care.

Too many states still don’t have Medicaid expansion, so too many people don’t have any care.

74/
2nd: We need long-term parental leave (up to 2 years per child) & full-time free, universal, early childhood education.
Even before free college.
We start kids at equity & their parents don’t go broke on daycare? College is attainable.

(here, for why: )
3rd: We need more student loan forgiveness & to limit how much private colleges can charge students in loans. (Ok, I want private colleges eliminated from any public funding, but I’m an absolutist on this — private education is segregation.)
(and an economic moral hazard.)
/76
4th: We need more poor kids, more kids of color & multilingual kids in psych.
I was poor, but I swam the system that wanted me to quit because I could code-switch into wealth & privilege when I had to. Which is why we need early education, loan forgiveness, & parental leave.
77/
5th: We need more therapists who are also clients.
It should not threaten licenses.
Anyone can get depression or anxiety.
We desperately need to support neurodivergent psychs through school.
Especially ADHD & anxiety, but every diagnosis.
Psych needs to be its own workspace.
78/
6th: we need more therapists, and we need to stop burning out young therapists by overworking them in the worst therapy jobs. Period.

(Also, pet peeve: dear judges, stay in your fucking lane. Do not diagnose from the bench. You are not qualified. Stop contributing to this.)
79/
7th: We need a concept of universal self-reflection. We’ve let the Scientologist view of therapy run too long.

Most 101 therapy can be taught in public school & works best as a community activity.
We can promote pro-social behavior & ID anti-social behavior as education.
80/
8th: if you’re lucky enough to have access to therapy: use it well. Make it your 3rd priority, behind sleep & work. Treat therapy like an emergency. Take it seriously. Do the work.
Being defensive doesn’t just waste your time & mine, it wastes other people’s access to therapy.
81
9th, and most important: we need a social safety net.
We need better child protection AND to keep families intact if their only issue is insufficient funds.
We need universal healthcare so children aren’t their parents’ caregivers.
Psych will NEVER substitute for social work.
82/
It’s improving. But it’s slow.
Our medical & mental health system is built on a fraught & faulty model. Our concept of self-reflection is tainted by Calvinism, capitalism & individualism.
We base our self-worth on flawed assumptions.
Thus we do the work.

~end

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