He was the dad who would visit during the school day just to sit next to me at lunch. We share a sweet tooth, so dessert has always been split down the middle, and we have the same sensitive heart. Neither of us can sit through a scary movie, which feels like a lovely plot twist for a man whose old unit inspired some of Hollywood’s most famous thrillers.

He also does not lead with his résumé. Unless you ask, and sometimes even when you do, he’ll credit luck, timing, and the people who helped him long before he names a single thing he accomplished. I didn’t grasp the depth of his work until he retired, when colleagues began coming up to me to share the impact he’d had on them and what he had done for them.

I’ve told him for years that he should write a book. Shows like Mindhunter and Criminal Minds have built whole storylines on the kind of work his unit did. He lived the real version, and then came home and split dessert with me.

Now in my late 30s, I understand how rare it is to keep admiring a parent, and to still aspire to be like them. So much of who my dad is feels wholesome, sacred, and caring.

People are often surprised to learn I was raised in a law enforcement family, with plenty of extended family who served in the military, too. In times this polarized and political, I understand why. But when I look at the people I grew up around, I see a shared commitment beneath the uniforms: protecting and serving their communities and their country so both could be stronger and safer.

I didn’t follow them into that kind of service. I carried the value somewhere else. As a therapist, I want my community to be safer and stronger, and the therapy room is where I get to do that work. I’m proud of where that value came from, and I hold deep respect for public servants and for everyone who runs toward the fire while the rest of us run away from it.

Here is the career behind the Waldo costume.

Dr. Stephen R. Band started out in the 1970s as a municipal police officer in New Jersey, holding a bachelor’s degree in psychology and a desire to help people. He earned a master’s in counseling, then a doctorate in counseling psychology at Fordham. He spent 22 years as an FBI Special Agent, helped build a program supporting the psychological health of undercover operatives, and eventually became Chief of the Behavioral Science Unit at Quantico. After retiring in 2005, he took on contract work in national security and police psychology. Then he opened a solo private practice, bought his own office condo, ran a consulting firm alongside it, and offered clinical supervision out of his suite.

On paper, that reads like four or five careers. When I asked him about it, he described one.

So I sent him 52 questions. For a man who rarely volunteers his own story, he answered every single one in writing. What came back was part memoir, part business manual, and part letter to his daughter, told the way only a natural storyteller can. I’ve kept his answers in his own words, with light cleanup for typos. His voice is the point.

I’m sharing his story because so much of what he lived is what we talk about here: career development, reinventing yourself more than once, and the qualities that carry a person from one chapter to the next. Credibility. Tenacity. The humility to learn from every role, and the foresight to prepare for the next door before the current one closes.

If you’ve ever worried that the road that brought you to this work was too winding, too late, or too unrelated to count, I hope his story offers you some inspiration. At the very least, I hope it makes you curious about the people who have influenced your own career, in one way or another.

The beginning: a psychology degree and a patrol car

What drew you to policing in the first place, and what did you think your career would look like back then?

Way back in the mid-1970s, perhaps like today, a bachelor’s degree in psychology was not a door-opener when it came to looking for a job right out of college; a desire to help people was the general theme. After much soul-searching, the influence of good friends and a healthy dose of naivety, I was drawn to becoming a police officer. I felt I was destined to grow professionally, and I came to grow emotionally, socially and physically on the street as a police officer. Looking back, idealistically, it was the best job I ever had! At times I found policing very physically stimulating, but not intellectually stimulating at the patrol officer level. This motivated me to pursue a Master’s Degree in Counseling.

You graduated from the New Jersey State Police Academy municipal police class and served as a police officer in the 1970s. What did street-level policing teach you about people that a classroom never could?

Police work exposes you to extreme violence; literally life and death situations requiring fast decisions; moments of stark terror and at times extreme boredom; witnessing the lives and deaths of people in more ways than I originally imagined; pushing through fear and at times receiving undesired recognition for acts of bravery. Growing up in a protective suburban environment, I never imagined assaulting a police officer. The first time it happens when you are the police officer is a bit of a shock… to which you must respond without hesitation. You have to get used to people looking at you as an object, not a person. The presence of a uniformed police officer evokes an emotional response in some people. When faced with people in their worst moments, in a multitude of circumstances and situations, applied psychology is always on the table.

At times it’s a raw art form employed magnificently by police officers with no formal degrees in the field.

When did psychology enter the picture? Was there a moment, a case, or a person that pointed you toward it?

After achieving the Master’s Degree, if I was to self-actualize, “being all that I could be,” for me that meant the next logical step was to at least attempt entry into a doctoral program. I was influenced by some Master’s Degree instructors, but mostly self-motivation. At the time I, again being a bit naïve, had no idea how hard it actually was to get into a doctoral program. I applied to several programs, rejected outright by all but one that invited me to an interview. At the interview I was asked what was my research interest. I said I was most curious about identifying the psychological attributes of a person who could survive an entire police officer career. Luck was on my side: the interviewer, a doctoral professor, had a similar interest in the facets of career development! Looking back, I absolutely marvel at my good fortune. The counseling doctoral program I entered was later to become accredited by the APA as a counseling psychology program. I could eventually sit for state licensing exams in both counseling and psychology.

Psychology entered the picture many, many years ago when I recognized that good mental health in both family and friends was critical to their success and happiness. If I could influence a person’s mental health in some positive way, that would be a worthwhile life endeavor. Being a police officer often put me on the front line of that worthy endeavor.

What was it like earning your doctorate in counseling psychology at Fordham while building a career in law enforcement? How did you manage both?

With great luck and fortune, I started my doctoral degree as a police officer. As my doctoral coursework moved forward, I realized it beneficial to create a bridge from policing to applied mental health. As difficult as it was emotionally, I left policing and worked at a large state hospital in applied forensic psychology. Later I found employment in emergency mental health services. It was from there I worked with police departments and eventually learned about the FBI’s early work in the applied behavioral sciences. In order to work towards a career in the Behavioral Science Unit, I had to become an FBI Special Agent. A return to law enforcement, and exposure to the other missions of the FBI, was on the agenda. Entry into an FBI career was extremely competitive; in my case, the completion of my doctoral degree was one of their requirements. I entered on duty with the FBI in December 1983. My doctoral diploma was mailed to me while I was in basic training at the FBI Academy.

The FBI years: two phone calls and a choice

What made you apply to the Bureau, and what was training like for someone who already had a clinical lens?

I wanted to apply for the FBI as an Agent upon completion of my bachelor’s degree, but I did not have the entry qualifications of an Agent candidate; years of professional experience beyond the bachelor’s degree was required. Upon completion of basic agent training at Quantico, my doctoral degree came secondary to learning the trade of a Special Agent. White collar crime, bank robbers, spies, counterterrorism, foreign counterintelligence was at the forefront of my journey. Entering the FBI’s world of applied behavioral science at Quantico was just a dream. There were field opportunities beyond investigative assignments to try one’s hand at applied behavioral science, such as police instructor, critical incident negotiator and cameo appearances at the FBI Academy Behavioral Science Unit (BSU)… this was long before the advent of today’s Behavioral Analysis Units (BAUs).

Your 22 years at the Bureau spanned counterintelligence, counterterrorism, undercover, and behavioral science work. How did one assignment lead to the next? Did you plan those moves or say yes to opportunities?

Inside the FBI there is every opportunity to make one’s interest known, but it is a very competitive environment where others equally qualified might have the same desired path. Again, opportunity must be coupled with luck and acquired skillsets in order to be competitive.

I was assigned to the New York office (NYO) of the FBI when the phone rang at my desk. The caller from FBI headquarters (FBIHQ) in DC was developing the idea of an FBI EAP. Having checked personnel records, the caller identified that I had a doctoral degree and asked if I wanted to leave NYO for FBIHQ to create the FBI’s EAP. To my surprise, I received a second call from Quantico asking if I was interested in the FBI’s undercover program to help assess the psychological health of undercover operatives. I knew that Quantico would give me greater exposure to the FBI’s Behavioral Science Unit while on assignment with undercover operatives. Having worked undercover, the choice was easy, but the process was still very competitive.

With great fortune and luck, the undercover program I was assigned to became a subcomponent of the Behavioral Science Unit… I finally arrived… but the journey was far from over. Many years of my career were spent at Quantico following assignments in Indianapolis, the NYO and special assignments to Chicago and southern California. I eventually became chief of the undercover component I was originally assigned. After achieving more skillsets and FBI career development requirements, my journey led to competing for and achieving the role of Chief of the FBI’s Behavioral Science Unit (BSU).

What did leading the Behavioral Science Unit actually involve day to day, beyond what people imagine from TV?

First and foremost, the BSU was evolving slowly from an operational unit into a teaching unit at Quantico. Our students were domestic and international law enforcement personnel as well as new agent trainees. The BSU was originally the home of Agents who became known as “profilers,” those who helped track and capture serial killers as depicted on TV and in the movies. The book Into the Minds of Madmen by DeNevi and Campbell depicts the evolution of the original BSU. The BSU’s reputation did draw TV and movie actors to the unit. They wanted to understand how to portray their roles, i.e., Jodie Foster for the movie The Silence of the Lambs, and during my time actors Ed Norton and Harvey Keitel with another Hannibal Lecter movie, Red Dragon. Day to day BSU operations focused on excellence in training our students in the applied behavioral sciences, creating national conferences focused on important topics like police suicide, managing death investigations, police psychology, police officer stress, critical incidents in policing, and of course operational support as requested.

You helped create and lead the Undercover Safeguard Unit, which supported the wellness of officers in undercover work. What convinced you those officers needed their own support system?

Research that preceded me indicated there are specific stressors associated with “pretending to be someone you’re not” in a hostile environment. Exposure to those stressors led to the detection of anomalous behaviors in some operatives. Monitoring the wellness, resiliency and readiness of undercover employees was conducted before, during and after covert operations to prevent tragedy.

What did building a unit from scratch teach you that applies to building a practice from scratch?

It taught me that prior research is critical to success.

You suggested the book that became the inside history of the BSU. Why did it matter to you that the unit’s story be told?

There was much mythology associated with the origins of the FBI’s Behavioral Science Unit; it was a team effort from its inception; unsung heroes were worthy of recognition. The popular media furthered misinformation about “profiling” serial offenders; it was a great history story that needed to be told.

What’s a lesson about leadership you learned the hard way?

Most lessons I learned can be put in the category of cliché: It can get lonely at the top. It’s important to remove administrative obstacles so your team can be optimally productive. Delegate what is appropriate; do not delegate your leadership away; devise a mission statement and plan to serve as the foundation of your goals and measurable objectives. Do not engage in mission drift, biting off more than you can chew. Take full responsibility: the buck stops here. Bring values to the job: Family First, Mission Always.

Being yourself in a leadership role and applying the best qualities of leadership role models is very important to success.

Delegate what is appropriate; do not delegate your leadership away.

The pivot: private practice is a small business

After retiring from the FBI in 2005, what made you choose private practice instead of something more structured?

After retiring from the FBI my security clearances remained active. Before they expired, I entered into the structured, lucrative world of contract work in the realm of national security psychology and police psychology; I was also recruited back to the FBI to assist as a contractor with undercover operations. As contract work diminished due to budget cuts and politics, as it just does, I decided it was time to fulfill the final chapter of my work life: private practice.

What scared you most about going solo, and what turned out to be easier than you expected?

I quickly discovered private practice is about running a small business that serves as a platform for professional counseling. You had to be competent and confident in both categories. For me both felt natural and professionally challenging enough to keep my interest and motivation for success piqued.

Private practice is about running a small business that serves as a platform for professional counseling. You had to be competent and confident in both categories.

How did your law enforcement and federal background shape the clients you attracted and how you marketed (or didn’t market) yourself?

I think the key word is “credibility.” Clients knew my background from my website before they walked in the door. Law enforcement agents and officers felt comfortable talking with someone who actually walked in their shoes. The trick is to find a niche that defines you; market that niche; build it and they will come. Don’t pretend to be someone you’re not. Word-of-mouth and referrals will play a huge role in building your practice. I brought credibility.

You bought a suite rather than renting. Walk me through that decision. What would you tell a clinician weighing buying versus leasing office space?

I rented a suite before I set out to buy an office condo for private practice. I would say there are business and tax benefits to both. For me, I saw the purchase as an investment and thought space rental would offset the mortgage payment. It’s a personal decision factoring in your financial and professional goals.

What did owning the space make possible that renting wouldn’t have?

Fulfilling financial goals: building equity.

You also ran a consulting firm, Behavioral Intelligence Specialists (BIS, LLC), alongside your clinical work. How did you structure the two so they supported each other rather than competed?

BIS, LLC was the platform for both the consulting business and private practice. In effect, income from both supported and complemented the other.

How did you set your fees in the early years, and how did that change over time?

Early on in private practice I decided to accept healthcare insurance. I hired a company that facilitated both credentialing and billing. Contract work was different. Being familiar with customary rates associated with contract work with private sector and government clients, I did not market myself above or below acceptable rates for the type of work being addressed.

What systems or habits kept your solo practice running smoothly, like scheduling, paperwork, and boundaries around your time?

Being your own boss is one of the perks associated with running your own business or practice. I set hours, boundaries and a schedule I knew I could fulfill. Importantly, I brought lessons learned from my many years at the FBI to help me establish administrative and operating guidelines. Past experiences truly guided me personally and professionally; an effective and efficient pace was achieved.

Supervision and mentorship

What led you to start offering supervision out of your suite?

I wanted to create a legacy; give back to the professional community that served me so well.

What did you look for in a supervisee, and what did you hope they’d walk away with?

I looked for professionals who were first and foremost deeply rooted in our ethical guidelines, knew their limitations of practice and felt comfortable practicing under supervision and all that meant. I hoped they would achieve the confidence and ability to diagnose, create treatment plans, use appropriate counseling techniques, and measure client progress.

What’s the most common mistake you saw newer clinicians make in their first few years?

Being overly confident and optimistic regarding client treatment outcomes; overstating optimism regarding client prognosis.

How do you think supervision changes when the supervisor has lived a career outside the therapy room?

Addressing supervisee curiosity about the supervisor’s life outside the boundaries of planned supervision hours.

The nonlinear path

Looking back, does your career feel like a straight line, a zigzag, or something else entirely?

Reflecting back on my career path, one step built on the next; it definitely had its ups and downs; not zigzags.

What skills carried across every role you held, from patrol officer to unit chief to therapist?

Being myself; bringing my own personality to the fight; not pretending to be someone I was not.

What would you say to a clinician who feels their previous career was “wasted time” before becoming a therapist?

All occupational, personal and familial roles prior to becoming a therapist have their value; perhaps not discovered or tapped into quite yet. Be introspective about that.

All occupational, personal and familial roles prior to becoming a therapist have their value; perhaps not discovered or tapped into quite yet.

How did you know when it was time to leave one chapter and start another?

Most of the time that decision was made for me; knowing it was inevitable, I began to prepare for the next step ahead. Good idea to look for a job while you still have one; not when you are desperate.

Mindset, doubt, and resilience

Was there a moment you felt behind, or worried you’d taken a detour you couldn’t recover from?

Mostly only with personal health; not career. However, a few times I found myself in an officer or agent role literally picking through garbage for evidence or on a traffic detail and thought I was somewhat overeducated or being underutilized. Nonetheless, it was a great lesson in humility.

Did you ever experience impostor syndrome, whether as a new agent, a unit chief, or a new therapist? How did you work through it?

Yes, I reflected on all the prep it took to get to that point in time and consoled myself best I could. Peer support also played a role.

Tell me about a failure or setback that later turned into one of your successes.

Family and friends thought I shouldn’t become a police officer because I had a college degree; back in the 1970s few police officers went to college; most had high school diplomas or GEDs. I inherently knew I needed this experience to bring credibility to my resume. A failure considered by others turned out not to be.

What doubts came up during your biggest transitions, and what helped you move forward anyway?

I did not know if I was ever going to be selected by the FBI due to the very competitive nature of their hiring; my fallback was a career in mental health emergency services, eventually leading to a general hospital administrative position, and secondarily private practice. Fallback and contingency plans defined my career life.

How did you recognize burnout in yourself, especially given the intensity of your earlier work, and what did you do about it?

Burnout for me was experienced as fatigue and the need to recover through sleep and/or very intermittent vacation experiences.

How did you handle rejection, criticism, or a plan that fell apart?

I looked at the source to determine the source’s credibility. If the situation was legitimate, I picked myself up, dusted myself off and started over again. Tenacity was one of my strengths; it’s important to find that in yourself.

What mindset shifts made the biggest difference in your career?

Knowing I had to leave the police department if I was going to achieve my goals; it was very tough leaving, but it opened many doors.

When doubt shows up now, what do you tell yourself?

I turn to introspective CBT and ask myself, what am I telling myself?… to discover the root of the doubt and try to act on those thoughts to shape my emotions.

Practical wisdom for clinicians

If you were opening a solo practice today, what would you do first?

I would study the local market to determine my primary source of income: insurance, clients who can self-pay; face-to-face sessions versus telehealth.

What’s one business decision you’d make differently?

Being a baby boomer, I did not grow up with any comfort around computers… I would familiarize myself with telehealth systems and software that could better manage key aspects of my practice, like taking and safe storage of clinical notes.

What role did professional networks and fellowships play in sustaining your career?

A substantial role in some circles, i.e., national security psychology; the law enforcement “family”; a post-doctoral fellowship in forensic psychology at Indiana University School of Medicine. All certainly sustained and defined my career.

How should clinicians think about adding consulting, training, or forensic work to a practice?

Think of it as a business product and work within your realm of credibility for maximum effect and financial payoffs.

You and me

What was it like coming home to a family after the kind of cases you worked on? How did you shift from agent to dad?

I learned to shift gears on the car ride home; as the door closed behind me at work, I knew it would be there the next day. Sometimes in my line of business, work followed me home or interrupted. I went with the idea: “Family First-Mission Always” and tried hard to keep priorities and maintain a balance. I tried not to act like a “cop” at home; just a dad.

When did you first sense I might be drawn to this field, and how did you feel when I told you?

I believed you had the right temperament at a very early age and believed 100% you could handle the challenge: I was right.

What did you think when I left academia for private practice?

It was a risk well worth taking in order to be all you could be. I was and am so very proud of you.

When I told you I was opening a practice, what was your first piece of advice?

Helping people is one thing, starting a business is another – private practice demands excellence in both. Be aware of how to achieve your source of income: insurance, self-pay; keep your eye open for consulting and speaking opportunities and let that and the practice play off of each other. Market yourself – don’t be shy or modest about that.

Helping people is one thing, starting a business is another – private practice demands excellence in both.

I chose a group practice while you stayed solo. What do you think of that choice, and what would you want me to watch out for?

Members of a group practice move on at times, be sure they only take with them what is theirs not yours. Help them on their journey.

We’re both clinical supervisors now. What do you hope my supervisees get from me that you tried to give yours?

I hope they have fond and grateful memories of the professional help you provided and carry with them your legacy of excellence and ethical practice.

What do you think I inherited from you professionally, and what is entirely my own?

I believe you inherited the capacity for empathy; the ability to feel what others are feeling and maintaining appropriate boundaries. The ambition and great courage to accomplish what you set out to do personally and professionally: you own that.

Our work looks so different on the surface. Where do you see the common thread?

Our common thread is caring for others.

If I ever wanted to pivot, the way you did more than once, what would you tell me?

Past is prologue… build on your previous steps and take it to the next level.

What would you want my readers to know about the daughter you raised?

I would want your readers to know she is “the real deal”… what you see is what you get: a genuine person and trusted professional.

Closing: the clinician never fully clocks out

What does retirement look like for you now, and does the clinician in you ever really clock out?

Retirement is an exercise in reflection and reinventing oneself. Your license requires you to maintain client records 7 years beyond retirement; just when you thought you’ve clocked out, a text or email arrives from a former client requesting records.

What legacy do you hope you’ve left, both in public service and in the counseling profession?

At the “end of my watch,” I hope to be remembered as a person who gave more than he took.

If you could leave one sentence for every clinician reading this, what would it be?

Exercise your sacred trust as a therapist in a manner that will always make you proud of yourself.

Exercise your sacred trust as a therapist in a manner that will always make you proud of yourself.

What I’m carrying forward

I’ve heard pieces of these stories for most of my life. Reading them in his own words, in order, I noticed things I had missed.

He never called it pivoting. Every move was a bridge he built on purpose: the patrol car gave him credibility, the state hospital connected policing to mental health, the doctorate opened the Bureau’s door, and the Bureau gave his practice a niche no marketing plan could invent. When a door was about to close, he was already preparing the next one.

He also talks about luck more than I expected. A professor who shared his research interest. A phone ringing at his desk. I don’t read that as modesty so much as accuracy. Luck showed up, and he had done enough preparation to recognize it.

And underneath all of it, the same four words he brought to the Bureau, to his practice, and to raising me: Family First, Mission Always.

If your path into this work came through another career, another country, another version of yourself, I hope you hear what I heard. None of it was wasted. It may just be waiting for you to put it to use.

What chapter before this work shapes how you practice today? Tell me in the comments. I’ll be reading every one, and so will my dad.

Leave a comment

When I published the first one in April, I figured a few grad students would find it useful and a few seasoned clinicians would nod along. I didn’t expect so many of you to write back with your own stories. The licensure application that went sideways. The supervision setup that fell apart. The moment you realized the field you trained for and the field you graduated into weren’t the same place.

(Confused? Here is the first essay: I’m Going to Be a Bummer)

Part 1 was mostly advice for you as an individual. Go in knowing. Understand the money. Build your community. I still stand by it. But since then, I keep coming back to a bigger question: how much of being prepared should rest on you alone? And what does our profession owe people before they walk in the door?

It wasn’t ever meant to be a series. But, here we are!

Stay with me. By the end, I’ll give you something to do with all of this.

My feed has become a support group.

Maybe it’s the algorithm. Maybe it’s the moment. Either way, my feeds are full of reels from pre-licensed therapists talking about how discouraged they feel.

Many of them are trying to break into private practice. A large share started grad school around 2020 or 2021, right when mental health moved to the center of the cultural conversation. Telehealth took off overnight. Demand surged. Therapy platforms were hiring fast. Talking about your therapist became normal, even a little cool. If you were picking a career back then, every sign pointed the same way.

That’s the world these clinicians trained in. It shaped what they pictured after graduation: momentum, full calendars, a field that needed them and would make room.

Then they graduated into a different climate. Some markets feel crowded. Some of the platforms that once looked like an easy on-ramp have cut what they pay. In late 2024, Alma and Headway lowered rates for therapists seeing clients with UnitedHealth’s Optum coverage, in some cases by as much as 30%. The data shows a shift in demand, too. APA’s latest practitioner survey found that clinician capacity seems to be leveling off after the pandemic, with burnout, waitlists, and trouble meeting demand holding steady or easing. That’s great news if you’ve been drowning. It’s harder news if you’re trying to fill a brand-new caseload, because demand is no longer outrunning supply everywhere.

Newer clinicians also seem to be carrying more of the strain. Burnout runs far lower among the most experienced practitioners, and the gap likely comes from everything newer clinicians are juggling at once: student loans, pressure to get established, and big life changes like partnering or starting a family.

They didn’t miscalculate. They made a reasonable bet based on the conditions in front of them, and the conditions changed.

These videos are telling us something.

It’s easy to scroll past these reels and write them off. Someone didn’t do their research. Someone expected too much. Someone’s just venting.

I see them differently.

Put together, they’re data. Not the scientific kind, but signals. When enough people entering the same profession keep naming the same surprises, it stops making sense to assume each of them failed to prepare. It makes more sense to ask what we failed to tell them.

So let’s walk through what they’re saying.

Much of the shock hits in year two.

The surprise I hear about most is internship. Before starting their programs, and sometimes well into them, these clinicians had no idea the second-year internship would probably be unpaid. Many also didn’t realize they likely couldn’t hold a full-time job while doing it.

If you’re outside the field, here’s why. In CACREP-accredited counseling programs, students first complete a practicum of at least 100 hours, then a 600-hour internship with at least 240 of those hours spent directly with clients. Those hours happen at a site, usually during the workday, with individual and group supervision built in, plus your classes. Try stacking that on top of a 40-hour job. For most people, the math doesn’t work.

There are exceptions. Some sites offer stipends. Some agencies pay interns. Some programs are built for working adults, and some students arrange placements through their current employer. Still, for a real share of students, year two is when income drops off a cliff. And they learned that after they’d already committed to the tuition, the loans, and rearranging their whole life.

The easiest fix: tell people up front.

I made my case about unpaid internships in Part 1, so I won’t rehash whether they’re fair. This is simpler. Tell people, clearly and early.

We already know how to do this. It’s called informed consent, and we do it with every client. We explain fees before the first session. We talk about the time commitment. We walk people through what the process will ask of them so they can decide if they’re ready.

We’d never let a client start treatment without explaining what it will cost them. Our programs can offer students the same courtesy.

This could go on the admissions page, in every info session and interview day, in acceptance letters, and on a timeline handed out at orientation: when practicum starts, when internship starts, roughly how many hours a week each takes, and what that usually means for your job. Add a sample budget worksheet while you’re at it.

So why doesn’t this happen more often? My guess is that it’s more systemic than sinister. Programs depend on enrollment. Faculty who trained decades ago did so when the finances looked different. And our field tends to assume people just know what they’re signing up for. Most don’t. How would they?

One slide in an orientation deck could spare someone a brutal second year.

Share Practice Forward

Your program wasn’t built to teach you business.

I want to stick up for grad programs for a second. (I know they make a very convenient, faceless villain at times.)

Lots of people get into this field with zero interest in owning a business. They want to see clients, work on a team, get a steady paycheck, and let someone else handle billing and marketing. Community mental health, hospitals, schools, the VA, agencies, college counseling centers: these are whole careers. A program built around clinical training is doing its job when it gets you ready for them.

And the word entrepreneur doesn’t excite everyone. For some of us it feels a little like hustle culture, like turning something meaningful into a sales pitch. That discomfort makes sense.

What has changed is the route people end up taking. For many new clinicians, private practice has become less of a dream and more of an exit. So people who never pictured themselves running a business are opening one anyway, with training built for a different destination.

Your program prepared you to start becoming a clinician. The market, (“this economy” ::shakes fist in air::) is asking you to be a clinician and a small business owner at the same time. Only one of those jobs have room on the syllabus. …Plus, how many of your professors actively see clients the way you aspire to?

Private practice isn’t the way out you might think it is.

Private practice often gets framed as the way to avoid community mental health. I understand why. CMH has a reputation for burnout, and much of it is earned. Agencies are often underfunded. Clients tend to come in with serious, overlapping concerns alongside housing instability, medical needs, and systems that have let them down. Caseloads can be huge, and a big part of your week may go to case management and paperwork instead of the fifty-minute session you imagined.

All true. Also not the whole story.

I worked in community mental health before I opened a practice, and I loved it. I had mentors who invested in me and supervisors who pushed me and had my back. I built my clinical confidence there, and I picked up skills I later used to run a business: documenting well, working across systems, understanding how funding shapes care. I know I may be the exception. Supervision quality varies wildly, and landing a good setup can come down to timing and luck.

Your first job after grad school may have looked very different: heavy caseloads, low pay splits, unpaid admin hours, strict noncompetes, and “supervision” that meant someone signing your forms. That happens in agencies and private group practices alike. If that’s where you are, leaving may be the right call, and it doesn’t make you difficult or ungrateful.

Or maybe the letdown is harder to name. In practicum and internship classes, you had a room full of peers and a faculty member whose job was to help you process. Then you graduate and learn your supervisor has their own caseload, several other supervisees, and maybe an hour a week for you. That space to process shrinks, and no one warned you.

Private practice doesn’t solve that problem. It can make it worse. In solo practice especially, no one schedules your consultation for you, and there’s no colleague down the hall after a hard session. You have to find support, build it, and often pay for it yourself.

The setting matters less than the people around you in it. When you’re choosing where to work, look for the people first.

Now you’re expected to be online, too.

Last time, I described marketing as making yourself easy to understand: a clear profile, your real voice, enough of you on the page that the right clients recognize themselves. For this group, the expectation has grown.

You probably didn’t enroll in a counseling program hoping to post. To share yourself, and pieces of your life, so strangers can decide whether to trust you. I say that as someone with two Substacks and considered creating a Buy Me a Coffee page. I didn’t train for this either. Most of us were taught to keep ourselves out of the frame. Social media asks for close to the opposite.

But newer clinicians are stepping into a different world. This past May, Pew Research Center reported that four in ten U.S. adults, and half of those under 50, get health and wellness information from influencers or podcasts. And among the thousands of popular accounts Pew studied, mental health professionals made up just 4%, while coaches accounted for 31% and entrepreneurs for 28%.

If licensed clinicians stay out of the feed, it doesn’t stay empty. Someone else fills it.

That leaves newer therapists in a spot no training program prepared them for. Being visible online has become part of the job for many clinicians, with real ethical questions about boundaries and self-disclosure, and almost no one teaches it. You can still build a practice through referrals and word of mouth, and many excellent therapists do. Either way, it’s now a decision you have to make on purpose, often without guidance.

If the idea of posting makes your stomach drop, that reaction makes sense. You were trained to protect the frame, and that instinct is worth keeping as you figure out what visibility looks like for you.

Share

Success stories leave out the how.

I’ve shared my own circumstances before because I think that kind of openness should be normal. What I want to add is what happens when others don’t.

Success stories usually show up as results. The full caseload. The new office. The waitlist. The month someone finally paid themselves what they’d planned.

The how rarely comes with them. Which referral source filled the caseload, and whether it still exists. Whether they opened before their local market got crowded. Whether a group practice owner sent them extra clients that first year. Whether they built an audience back when the algorithm rewarded anyone who posted consistently. How many years passed between their first client and the first month that covered their bills.

Timing matters more than people admit. Advice that worked in 2019 or 2021 gets packaged and sold in 2026 as if nothing changed. For this group, that difference is everything.

When the how stays hidden, newer clinicians compare themselves to half a story. When their results look different, they decide the missing piece must be them. For someone just starting out, a result without context can read like a verdict.

Why so many therapists have a second income.

You may have seen the accusation that being a therapist has become a Ponzi scheme: build a practice, or at least look successful online, then pivot to selling courses and coaching to the therapists behind you.

I’m less interested in whether that label is fair and more interested in why so many therapists are earning money outside the therapy room.

Clinical income has a ceiling. There are only so many sessions in a week, and only so many your nervous system can hold well. And insurance pay has been stuck. When ProPublica talked with dozens of therapists, they described reimbursement rates that had barely shifted in years. So clinicians diversify, and I’m one of them. I train, consult, write, and run a professional community alongside my practice.

The course launch is just the version you see. Spend time in therapist forums and peer support groups and a different reality shows up. Clinicians talk about driving for DoorDash between sessions, selling handmade goods on Etsy, and walking dogs on weekends. For some, the reason is simple: they need the money. For others, it’s about avoiding burnout. They want work that uses their hands and feet instead of their capacity to hold someone else’s pain, work that ends when the shift does.

When a clinician with a master’s degree needs a delivery app to make rent, that tells us something about pay. When they look for work with no emotional weight just to recover, that tells us something about workload. For one therapist the side hustle is a course. For another it’s a dog leash. Same economics, different answers.

If you’re one of the people picking up shifts between sessions right now, I see you. Doing what you need to do to make the numbers work isn’t small, and it isn’t evidence that you failed.

Selling a course can be a perfectly honest way to share what you know. What worries me is a field where teaching other therapists can pay more reliably than treating clients. The long term impact is not having dedicated time to learn your craft.

Subscribe now

Put it all together and a pattern shows up.

Line these up side by side: the unpaid internship, the business skills, the hope that private practice would be easier, the pressure to become visible online, the missing how, the second jobs.

Then look at why so many of these clinicians say they post in the first place. Some felt unprepared for practice and don’t want the next person to feel the same. Some learned about the long road from degree to license only after they were on it. Others post because they believe this information should be easy to find, and they rarely saw their own experiences, identities, or questions reflected in their training.

Nearly every one of these points back to the same place. When this many clinicians are using social media to teach each other what school didn’t, we’re looking at a gap in how we train people.

The fix has to start upstream.

I spent time in academia before I moved into private practice, so I know how this looks from the faculty side. Professors aren’t hiding information. They’re working within credit limits, accreditation requirements, and a list of must-teach content that grows every year. Whatever the standards require gets class time. Whatever’s optional tends to get squeezed out.

So let’s look at the standards. Each discipline has its own accrediting body. Counseling is my world, so I’ll speak to CACREP.

Here’s the encouraging part: CACREP’s 2024 standards already require programs to hold a new student orientation where licensure eligibility and requirements are reviewed. The structure for telling students hard truths up front already exists.

As I read the standards, though, that orientation isn’t asked to cover the rest of the picture. What internship will likely do to your income. How long licensure tends to take after graduation and what it costs. How insurance reimbursement works and why it shapes nearly every setting. What good post-grad supervision looks like and how to tell when you’re not getting it. How to build a career you can sustain, in private practice or anywhere else.

Programs don’t need to become business schools. But if CACREP can require an orientation that covers licensure, it can require that same orientation to cover what internship will cost students in time and income. It can treat career sustainability as a core skill instead of a single guest lecture. And the same conversation belongs at COAMFTE, CSWE, and APA for the programs they accredit.

We’re graduating clinicians who may be clinically ready for the work and still underprepared for the career around it.

What you can do from where you are.

First, the part that gives me hope. These reels are doing something my generation mostly didn’t. When I was starting out, most of us swallowed the shock and assumed we were the only ones struggling. This group is saying it out loud. In a real way, they’re crowdsourcing the informed consent their schools never gave them. And peer spaces are growing alongside them: forums where people trade referral lists and fee scripts, and consultation groups for clinicians who never saw themselves in their training. I started Asian Therapists in Private Practice for that exact reason. When the resources don’t exist, we build them.

If you’re frustrated with this field, it’s because you expected better from it. Hold on to that. It’s how fields change.

Now, depending on where you are:

If you’re thinking about grad school, go to info sessions with your questions ready. Ask these out loud, and write down the answers:

• Is the internship paid, and if not, how many students keep a job during it?

• How many hours a week will year two realistically take?

• How long does it usually take graduates to get licensed in this state, and what does that process cost?

• What do post-grad supervision jobs around here actually look like?

If a program can’t or won’t answer, that tells you something too.

If you’re pre-licensed, interview your next job as carefully as it interviews you. Ask how supervision is set up and how many supervisees your supervisor has. Ask about the pay split, whether there’s a noncompete, and who loses the income when a client cancels. Keep posting if it helps you, and make sure you also have one place, whether that’s a consultation group, a peer circle, or a trusted colleague, where you can say the hard thing out loud without it becoming content.

If you’re established, share the how. Tell people what it really took, including the parts that don’t fit in a caption. If you supervise, make it the kind of supervision you wish you’d had. If your caseload is full, send your extra referrals to the newer clinician down the street.

If you teach or run a program, add the slide this semester. And when your accrediting body releases its next round of draft standards for public comment, show up and push for disclosure and career sustainability to become requirements. CACREP built its 2024 standards through four public comment drafts. Those comments count.

And if this resonated, send it to someone standing at the start of this road. Then come find me in the comments and tell me: what’s one thing you wish someone had told you before you got here? Let’s build the list they didn’t give us.

Still a bummer. Still here.

Some of what I’ve described is slow and structural, and one Substack essay won’t fix it. But a few pieces could change this admissions cycle, and none of them require new funding. They just require deciding that the next group deserves to know what they’re walking into.

I’m still here, still doing this work, and still really glad I chose it. For those of you coming in behind me, I want you to walk in informed and supported. And when it gets harder than the reels promised, please don’t take the difficulty as proof you that you’re not cut out for this or that you don’t belong. Some of what you’re carrying is yours to learn. Some of it belongs to a profession that needs to do better by the people who come next.

Some of you who are close to me, and those who follow along on LinkedIn, know that I recently took a much-needed break before returning to work.

Usually, I save my longer stretches of time off for the winter holidays, so intentionally stepping away in the middle of summer was unusual for me! Without getting too deeply into it, I needed some space to rest my mind and prepare my body for my second round of IVF. Hiking, yoga, massage, and being surrounded by wide-open sky and stars turned out to be exactly what I needed.

Since we last spoke, our Asian Therapists in Private Practice community also had the joy of welcoming my good friend Dr. Stacey Diane Arañez Litam. She shared insights from her book, Patterns That Remain: A Guide to Healing for Asian Children of Immigrants, along with what inspires her, what she’s thinking about now, and what may be next for her.

And if you’re an Asian therapist and would like to join us for our next monthly virtual hang, fill out our Google form and I’ll add you to our listserv. I’d love to have you in the community!

NOW…

Rested and back in the room with clients and supervisees, I’ve been thinking about something that’s been nagging at me for a while. So, I am writing an essay in the “Craft & Critique” section of my Substack today. This one, I hope stirs something in you, as I think all effective cultural critiques should. ;)

As an Asian American therapist—and as someone who is mixed, straddling multiple cultural worlds—I use the language of collectivism and individualism regularly. It gave me words for things I didn’t have language for.

But lately, I’ve watched these terms do something I didn’t expect—something that starts out helpful and ends up reductive.

And I think it’s because I’ve spent my whole life in the space between. I know what it feels like to want two things that don’t fit in the same hand. To belong to something and to belong to yourself. To be held by a community and to need room to move. Not as a stage you graduate from. Not as a contradiction to resolve. But as the ordinary condition of being a person.

So when I watch the field turn “collectivism” and “individualism” into opposing teams, into a villain and a hero, into something you have to choose—I recognize the impulse. But I also know how much gets lost when we stop seeing the both/and.

Subscribe now

The essay

Open whichever app you use and you’ll find it inside of ninety seconds...

A carousel explaining that if your mother calls three times a day, that’s enmeshment. A reel telling you that guilt about disappointing your family is a trauma response. A caption assuring you that anyone who doesn’t respect your boundaries doesn’t respect you.

Scroll a little further and you’ll hit the correction. A post explaining that Western therapy pathologizes collectivist cultures. That closeness with your family is not a disorder. That individuation is a Western import.

Both are reaching for something real. Both are compressing an enormous idea into a container small enough to share.

And clinicians are absorbing the compression too. I hear it in consultation. I hear it in supervision. A client gets described as “from a collectivist culture” the way you’d note their insurance panel, and that description is doing an unreasonable amount of work.

We are very fast with a name

I don’t think the reflex is malicious, and I understand where it comes from.

This field trains us to name quickly, and sometimes the name brings relief. When you’ve spent years feeling like the only person who reacts the way you react, finding out there’s a word for it can reorganize how you see yourself. I’m not interested in taking that from anyone.

But when the name becomes the beginning and the end of the work, cultural concepts start behaving like diagnostic codes. Assigned early. Filed. Never revisited.

A category tells you what to call something. It doesn’t tell you what the thing is doing in this person’s life.

Culture gets filed that way more often than we admit.

The shorthand was never an assessment

Western equals individualistic, Eastern equals collectivistic. Serviceable in a graduate seminar. It falls apart the moment an actual person sits down.

Cross-cultural research has long complicated that binary. Individualism and collectivism coexist inside the same country, the same ethnic group, the same family, the same person, and which orientation surfaces depends heavily on context. Studies spanning dozens of nations have documented substantial variation within national groups, and researchers have been explicit that you cannot infer someone’s orientation from nationality.

So let me define the terms carefully, because the precision matters more than it sounds like it does.

Individualism refers to values and practices that emphasize the person as an autonomous agent—self-direction, personal goals, individual choice, self-expression, independence.

Collectivism refers to values and practices that emphasize the person as embedded in relationships and groups—interdependence, shared goals, obligation, loyalty, cooperation, the maintenance of important relationships.

Here’s what gets dropped in translation: these are not personality types, and they are not opposite ends of one dial. Someone can hold a fierce commitment to autonomy and a deep sense of responsibility to a community, at full volume, simultaneously. The literature offers the ordinary example of a person who is competitive and independent at work and thoroughly interdependent at home. That isn’t a contradiction to resolve. That’s Tuesday.

What the binary is actually tracking

If the East/West framing is this inaccurate, it’s fair to ask why it has lasted as long as it has.

I don’t think it survived because clinicians are lazy. I think it survived because it’s pointing at something true and filing it in the wrong place.

Underneath the geography is a tension that belongs to everyone. We want to be our own, and we want to be someone’s. We want to author a life, and we want that life to be held inside something that outlasts us. Neither want is a developmental stage you graduate from. Neither one goes quiet once you’ve chosen the other. They just take turns being loud.

You’ve watched this in the room. The client offered a job in another city who cannot explain why she hasn’t said yes, and then mentions, twenty minutes later, that her mother has hosted Sunday dinner since 1994. The man who took over his father’s business and resents it and would not sell it for any number you named. The person who has finally built the life nobody in their family understands and calls them anyway, every week, from inside it.

None of that is culture clash. That’s the ordinary condition of wanting two things that don’t fit in the same hand.

The binary’s real appeal is that it takes an argument happening inside one person and reassigns it to two civilizations.

Which is relieving, and the relief is worth watching closely.

History is often genuinely in the room. Migration, racism, assimilation, colonization, the specific bargain a family struck to get somewhere—none of that is decorative, and a client who names it is usually naming something accurate about why the tension exists in their life and not in someone else’s. I’m not arguing that culture is a story people tell to avoid themselves.

I’m arguing that it can become the complete story. If my ambivalence is fully explained as a collision between East and West, I no longer have to hold it as something I’m also personally negotiating, in a life only I’m living. The conflict gets a passport. It travels somewhere I don’t have to follow.

Clients reach for that, and so do we. It’s easier to formulate a culture clash than to sit with someone inside a tension that has no resolution and isn’t supposed to have one.

And once the two wants belong to two civilizations, therapy has an obvious job: pick the right one. Which is how you get both failure modes at once. The individuation-heavy version treats the pull toward belonging as the obstacle—the thing keeping the client from the life they’d have if the family would just loosen its grip. The overcorrected version treats the pull toward autonomy as contamination, evidence of assimilation, a Western want the client absorbed and should return to sender.

Both relieve the person of a tension they need to keep carrying.

Collectivism isn’t an ethnicity

In culturally responsive training we’ve spent real effort teaching clinicians that family obligation, relational decision-making, filial responsibility, and interdependence may be culturally meaningful rather than automatic evidence of enmeshment, codependency, or insufficient differentiation.

That work needed doing. It still does.

But we built a second stereotype on top of the first. The corrective told us not to pathologize interdependence in Asian, immigrant, and other minoritized families—and then quietly implied that interdependence is where those families live and where everyone else doesn’t. Collectivism became something we go looking for in some clients. A white American client walks in and we default to the individualistic frame without noticing we’ve defaulted to anything.

We assign the cultural formulation to some clients and not others. And then we call the whole process culturally responsive.

That isn’t a failure of the corrective. It’s what happens to any corrective absorbed as a rule about demographics instead of a habit of curiosity.

The better question isn’t which culture someone comes from. It’s what groups this person believes they belong to, and what belonging there requires of them.

I’ve sat across from people who make this obvious.

The daughter who moved back home at thirty-four to care for a parent and doesn’t experience it as sacrifice, exactly, but can’t tell you the last time she made a plan that was only hers. She isn’t looking for permission to leave. She’s looking for a way to stay that doesn’t cost her everything, and every framework I was handed in graduate school wanted to hurry her toward the door.

The veteran carrying combat trauma who will describe his unit before he describes his symptoms. The people he served with are not a support system in the way our paperwork means it. They’re the reference point for who he is and what he owes. Ask him to prioritize his own recovery and you’re asking for something that feels, to him, like a form of desertion. Maybe there’s avoidance in there too. But if we can’t see the value underneath it, we’ve misread what he’s avoiding and why.

The public servant sitting on a resignation letter for eight months. She can tell you what the job is doing to her body. She can also tell you who covers her portfolio if she goes, which colleague is already underwater, and what happens to the work when the institutional memory walks out the door. She isn’t stuck because she lacks insight. She’s stuck because leaving means abandoning a team and a mission, and “you have to put yourself first” is a sentence that lands as an accusation.

None of these three would get flagged as collectivist at intake. Two of them are white. One would tell you her family is “not close.” The self sits outside the individual in all three cases, and nothing on the demographic form would have caught it.

And as I write this, Dolly Parton has just died, which has made me think about this in another way. There may be few people who embodied individuality more visibly than Dolly. She built an unmistakable identity, made enormously self-directed choices, and seemed almost defiantly herself. And yet so much of what she built kept circling back to the people and place she came from. Her Imagination Library began with children in her home county. She invested in education there, created a fund for families who lost their homes in the Smoky Mountain wildfires, and built businesses that became part of the economic life of the region.

I don’t know what language Dolly herself would have used for any of this, and I’m not interested in retroactively assigning her a cultural orientation. But her life is a useful reminder that autonomy and collective responsibility were never opposites to begin with. You can build something entirely your own and still understand your success as connected to the well-being of other people. You can leave home and remain accountable to it. You can become extraordinarily individual without imagining yourself as only an individual.

You can keep going. First responders. Rural communities where everyone’s grandparents are buried in the same three plots. Multigenerational family businesses. Faith communities where major decisions run through obligations to tradition, to congregation, to God—and where “choose what makes you happy” misreads the architecture of a meaningful life at the foundation. Activist movements. Disability communities. Our own profession, with its martyrdom norms and its quiet contempt for anyone who takes a full lunch.

These are not equivalent cultures and I’m not flattening them into one.

Collectivism shows up anywhere people locate themselves partly through membership, obligation (indebtedness), shared meaning, and belonging.

Which is most people, if you’re paying attention.

Share

I use the word too

I should be clear that I’m not writing this from outside the vocabulary.

I use collectivistic all the time—to describe the family norms I inherited, the ones I watched operate in my parents’ house, the ones I still catch myself running when I’m deciding whether I’m allowed to say no to something. It’s a useful word. It named a set of expectations I had no language for until well into adulthood, and it let me stop treating those expectations as a personal failure of assertiveness.

So this isn’t an argument for retiring the term.

It’s an argument against what the term gets recruited into.

Now it seems that “collectivistic” stopped being descriptive and started being a position. It became the good pole. And “Western,” “individualistic,” and increasingly just “therapy” became the thing we’re pushing against—the ideology that did this to us, the framework that got it wrong, the villain of the story.

“Western therapy” is a compression too, and a large one. It collapses feminist, systemic, relational, community, liberation, attachment, and existential traditions, many of which developed partly in response to narrow ideas about the autonomous self, into a single imagined ideology. The same move we’re objecting to, pointed the other direction.

(Separate, but related note, that deserves it’s own essay: Some therapists have also argued that many of the frameworks we treat as standard need to be decolonized, meaning we should be asking who created them, whose values they reflect, and whether they make enough room for different cultural ways of understanding pain, healing, family, identity, and relationships.)

I understand the pull. A villain organizes an argument beautifully. It gives the harm somewhere to go.

But I can’t honestly tell you one is better than the other. I’ve watched the norms I inherited hold a family together through things that should have broken it. I’ve also watched them make it nearly impossible for someone in that family to say they were struggling. Both of those are the same value system. It didn’t switch teams.

And the autonomy language I was trained in—the self-direction, the boundaries, the permission to want something for its own sake—has been useful to me in ways I won’t pretend it hasn’t, just because it arrives with a suspect passport.

Every conversation about this distills into which one is better. That’s the part I want out of.

Because the moment a framework becomes a side, it stops helping you see a person and starts helping you sort them.

Neither orientation is automatically healthy

Collectivism offers extraordinary protective resources. Belonging. Mutual aid. Shared responsibility. Continuity across generations. Purpose. Caregiving that doesn’t have to be negotiated. The knowledge that you will not have to survive this alone.

And the mechanisms that make a group protective are the same ones that make it capable of harm.

Loyalty becomes silence.

Harmony discourages dissent.

Shared identity becomes pressure to conform.

Sacrifice becomes exploitation.

A group that supplies someone’s entire sense of belonging holds outsized power over what that person feels permitted to question.

One more distinction, because we collapse it constantly: hierarchy and collectivism are not synonyms. Cross-cultural researchers separate horizontal and vertical forms of both orientations precisely because groups differ in how much inequality they treat as natural. A community can be intensely interdependent and relatively egalitarian. Another can be interdependent and steeply stratified. Those produce very different clinical pictures, and the same client can belong to one of each.

Better questions

Instead of asking whether a client comes from an individualistic or collectivistic culture, ask where they locate the self. Then get curious.

Which communities matter enough that their approval shapes your decisions? Who do you believe you owe something to? What does loyalty mean here? What happens when someone disagrees? Who is protected by these norms, and who pays for them?

And then the pair I’d build an entire assessment around:

1. What does belonging to this group give you that you don’t want to lose?

2. What would choosing yourself cost you relationally—not in theory, but by name?

Ask only the second and the assessment tilts deficit-oriented without your noticing. You end up cataloguing what a person’s community takes from them and never once documenting what it provides, which is its own cultural misreading and a considerably more flattering one to hold.

Ask both and you’ve put the real tension on the table, in the client’s own terms, without either of you having to decide which side is correct.

Share

Six things this changes

Critique that doesn’t touch the work is just a better-informed opinion. So here is what I’d actually do differently.

• Put the belonging questions in your standard intake, not your clinical judgment. If asking about groups and obligation is something you do when a client seems like they’d have some, you will keep asking the clients you already read as cultural and skipping the ones you don’t. The bias doesn’t live in the question. It lives in the decision about whom to ask. Take that decision away from yourself by asking everyone.

• Name the actual group in your formulation, never the category. “Client’s decision-making runs through his former unit; he evaluates choices against what his platoon would think of them” is usable by you, by his next provider, by a reviewer. “Collectivist values” is decoration. One tells the reader something. The other tells them you attended a training.

• Check whether your treatment goals assume a free-standing agent. Most templates do. “Client will set boundaries with mother” and “client will prioritize self-care” both presume a person who can move without anyone else moving. For the public servant, the goal isn’t leaving. It’s identifying what would need to be in place—coverage, a successor, a conversation with the colleague who’s underwater—before leaving stops registering as abandonment. Same destination, but now the plan matches the terrain she’s standing on.

• When the group is causing harm, work in the smallest available increments. You don’t tell someone to leave a community that constitutes their entire sense of self. You help them test whether it can tolerate a very small deviation. Decline one request. Voice one mild disagreement. Then look together at what actually happened. Sometimes clients predict catastrophe and encounter disappointment they can tolerate. Sometimes the catastrophe arrives on schedule. Both are important information, and it’s information they gathered rather than a conclusion you handed them.

• Retire three sentences. “You have to put yourself first.” “You don’t owe them anything.” “That’s a boundary issue.” Each is true in some rooms and an accusation in most of them. Replace them with questions about cost and benefit, which get you to the same clinical territory without requiring the client to first agree that their people are the problem.

• In supervision, audit whose file has a cultural formulation. Pull ten charts. If the cultural conceptualization shows up for your immigrant clients and your clients of color and goes missing for the white ones, you’ve found the bias in a form you can actually fix. Supervisees generally receive this well, in my experience, because it’s specific and it isn’t about their character.

Cultural responsiveness doesn’t mean automatic validation of a cultural practice. It means grasping what a practice means and does before we decide what we’re looking at. You can hold real respect for why loyalty, hierarchy, sacrifice, or harmony matters to someone and still help them examine whether those values are being used to keep them quiet.

Both things. At once. That’s the job.

Less certain, not better calibrated

I don’t think the creators making those carousels are acting in bad faith. Most are trying to give language to people who’ve never had any. The problem is structural: short-form rewards clean categories, punishes qualification, and rewards a villain most of all. That’s how a descriptive term ends up as a team jersey. By the time the vocabulary reaches your office, it has hardened into a diagnosis your client has already given themselves.

Which leaves us doing the slow work of putting the nuance back. Against every incentive, in fifty minutes, with a treatment plan due.

But I want to be exact about what that work is, because I think we’ve described it wrong. Cultural responsiveness is not getting better at matching demographic categories to their presumed values. That’s the same reflex with better manners—faster, more confident, still sorting.

It’s becoming less certain that we know where someone’s culture begins and ends.

Cultural humility asks us to broaden which cultures we recognize. It should also ask us to broaden what we’re willing to count as culture in the first place—including the ones that look, at a glance, like nothing more than a job, a unit, a church, or a mother who calls three times a day.

And underneath all of it, the same two wants, in an arrangement particular to the person sitting in front of you: to belong to something, and to belong to yourself.

Nobody has ever resolved that. There was never a box for it on the form.

It was a gateway.

Underneath every “what should I do with my life” question was something else—a values conflict, a family script, a question about worth in a culture that measures people by their productivity.

I understood that career counseling was one of the few places where clients would talk openly about privilege, risk tolerance, and the sociopolitical weight sitting behind every “practical” decision they were making.

Not to mention, growing up, my parents held tight to the idea of meritocracy—the belief that hard work in America could open just about any door. So understanding how to help people navigate career issues, decisions, and development felt less like a choice and more like a direct connection to understanding cultural influences on our mental health and well-being.

Even before teaching master’s level students, I got my master’s in Rehabilitation Counseling and spent my early career doing vocational rehab with veterans—running career groups, connecting people to resources and funding, watching what it looked like when someone’s sense of self had to be rebuilt alongside their resume.

Later, the same instincts showed up when I became a clinical supervisor, mentoring graduate students figure out who they were as clinicians, not just what they’d been trained to do. I also volunteered with the National Career Development Association for years, contributed to their Career Convergence publication a few times, eventually keynoting one of their conferences and training their leadership board.

…And to top it off, live in the DC metro area, where “so what do you do” is basically the opening line of every conversation you’ll have at a party. Career isn’t a side conversation here. It’s the main event!

All of which is to say: I’ve spent a long time thinking about how people build careers.

Subscribe now

Dust off your career counseling knowledge…

One of my favorite frameworks in this space is Planned Happenstance—sometimes just called Happenstance Theory. John Krumboltz built it as a direct challenge to the idea that a good career comes from careful planning and one correct match between person and profession.

His argument was messier, and truer (in my experience): most meaningful careers get shaped by chance. Unexpected conversations. Layoffs nobody wanted. Opportunities that had nothing to do with the plan.

You can’t predict every opportunity. But you can become the kind of person who recognizes and acts on one when it shows up.

That’s the whole theory—simply put. It has nothing to do with sitting back and trusting the universe, and everything to do with building a muscle.

Share

How this is applied

Think about how careers really unfold, once you stop pretending they follow a straight line. Someone volunteers for a project and stumbles into a passion they didn’t know they had. A hallway conversation at a conference turns into a job. Someone from a former team remembers how passionate you were about a particular project and calls you years later. A layoff becomes the reason someone finally starts the business they’d been talking themselves out of for years.

(Orrr…you write a Substack for fun-zies and you get to meet some incredible people and partnerships through its readership!)

From a Happenstance lens, none of that is really luck. It’s readiness—someone already primed to notice the opening and act on it.

Krumboltz named five skills behind this kind of readiness, ones you build deliberately over time.

• Curiosity. Explore something outside your lane just because it interests you. Take the class that has nothing to do with where you think you’re headed.

• Persistence. Keep showing up after the setback, the rejection, the thing that didn’t work. Persistence isn’t a personality trait—it’s a decision you keep making.

• Flexibility. Let go of “this wasn’t the plan” and get curious about what the change actually opens up. At bottom, it’s just a willingness to revise.

• Optimism. Not toxic positivity—the harder, quieter kind. Believing that possibility can exist inside uncertainty, even when the uncertainty is unpleasant.

• Risk-taking. Reasonable, not reckless. Reaching out to someone you admire. Applying for the role you’re only seventy percent qualified for. Starting the side project before you feel ready.

Share

What this means in the therapy room

Traditional career counseling asks: what are your interests, your values, your personality type, and which occupation checks those boxes.

Krumboltz asks something different:

• What unexpected things have already shaped your life?

• How do we put more good surprises in your path?

• What could you try this month, not five years from now?

• What relationships or rooms would put new possibilities in front of you?

The shift is subtle but it changes everything. It’s the difference between finding the right career and building the conditions where a right-enough career finds you.

Say a client sits down and says, I don’t know what I want to do.

Instead of chasing the one perfect answer, you might send them toward an industry meetup. A day of shadowing someone. A volunteer shift. One informational interview. One class that has nothing to do with anything, except that it’s interesting. Each of those is a small bet on happenstance, a small investment in themselves. An opening, not a full plan.

Subscribe now

Where the theory falls short

Okay, okay…I’d be doing the theory a disservice if I didn’t name the obvious critique. Happenstance can underplay how unevenly opportunity gets distributed in the first place.

Not everyone has the same access to chance encounters, the same financial cushion to take a risk, the same freedom to say yes to the unplanned thing—not when discrimination, immigration status, disability, or caregiving are also part of the equation.

The therapists doing this work well now tend to hold both questions at once: how do we help someone create more opportunity, and what structural barriers are actually in their way, and how do we navigate or push against those barriers rather than pretending optimism alone will do it.

Leave a comment

“In this economy?!”

In private practice, hardly anyone’s path is a straight line anymore.

Most of us built what we have out of a series of relationships, side hustles, unplanned invitations, and identities we didn’t see coming—not a tidy plan we followed to the letter.

(Sometimes I low-key wonder: “Is every therapist’s side hustle to teach other therapists how to side hustle?” It’s hard not to get discouraged and think that our profession has turned into one big MLM (multi-level marketing) scheme).

Here’s what I am asking you to consider: You don’t have to predict your future career. You have to become someone who is prepared to recognize and act on the opportunities you couldn’t have predicted.

Career development as building the kind of adaptability and intentional risk-taking that lets you recognize the door when it shows up.

Why I’m telling you all of this? Because, don’t think for an instance I have a strategy.

Because private practice ownership is Happenstance in its purest, most chaotic form. Nearly everything I know now about running a business came from doing the thing, getting it wrong, and paying attention to what the wrongness taught me—not from a plan I made in advance.

That’s both the maddening part of small business ownership and, if I’m honest, the part I’ve come to enjoy.

So here’s the honest list—what I wouldn’t do again, and what I’d do exactly the same way.

Expanding: I paid for too much office rent. If you want to offer in-person sessions and you’re building this from scratch, look for a sublease, or a space you can rent by the hour or by the day. Your caseload’s workflow—how much of it wants to be in-person versus virtual—is hard to predict in advance. If your modality is something like somatic work, where the body in the room matters, fine, that’s a clear case for a dedicated in-person setup. Otherwise, you’re guessing. I signed a lease before I had the data to justify it, got excited about expanding, moved too fast, and ended up not renewing contracts because the office was just sitting there, expensive and empty.

(I’ve also heard plenty of cautionary tales about clinicians expanding too quickly by bringing on too many therapists at once, forgetting that you often lose money before you make money while each clinician builds their caseload, especially once you factor in all the subscriptions, systems, and overhead connected to each new hire.)

Taxes: I didn’t pay quarterly taxes. If you were ever part of Asian Therapists in Private Practice, you heard me talk about this more than once, usually right after our CPA friend came through to explain it to the group. Being surprised by a lump sum you owe the IRS is never fun, and it comes with real sticker shock. I didn’t understand what self-employment meant for tax withholding, and I definitely wasn’t thinking about it in terms of retirement.

Retirement: Which is really the same mistake wearing a different outfit. I wasn’t thinking long-term about my financial future. If I could do it again, I’d figure out early what a reasonable contribution to a retirement account looked like for me—knowing I could always adjust it later—and I’d actually start. And here’s the part that trips up other clinicians too, even ones who do open the account: opening it isn’t the finish line. If the money’s just sitting there uninvested, it isn’t earning anything. You have to actually buy something with it.

Opening a retirement account isn’t the finish line. If the money’s just sitting there uninvested, it isn’t doing anything for you.

Bookkeeping: I didn’t separate my personal and business accounts. This one made bookkeeping a nightmare right away, and I course-corrected fast because the headache wasn’t sustainable. Open a business bank account. Get a business credit card. Keep them as separate as you can stand to. If you’re ever unsure what counts as a business expense, your CPA can tell you, or a reasonable amount of that information is just sitting online for free.

Growing Too Quickly: I said yes to too many people, too early. This is the scarcity mindset almost everyone starting a practice knows intimately—the pull to build your caseload by saying yes to whoever calls. I was more selective than most, but not as selective as I should have been, even though I already had a fairly specific niche in mind. The real mistake sitting underneath that one was accommodating everyone else’s schedule instead of my own. I worked back-to-back, with no real breaks, and it took longer than it should have to admit that wasn’t sustainable.

Visibility: I wasn’t consistent or visible early on about community partnerships. Relationships with other small practices, medical offices, potential referral partners—those take time to build, and they’re not transactional. I wish I’d let people know I existed sooner. An email. A postcard, if you’ve got the budget for it. Sometimes just showing up in person to say hello does more than either.

Saying Goodbye When It’s Time to Grow: I stayed with a biller who only worked with solo practices for too long, well after I’d grown into a group. I should have made that switch the moment the mismatch became obvious instead of waiting for it to actually cause problems.

Limited My Referral Base: I leaned on directories as if they were a growth strategy. They’re not. A directory listing is a place to claim your legitimacy—a box that says you exist and you’re credentialed—not a place that reliably sends you clients.

Leave a comment

What I’d do exactly the same way

DYI: I built my own website. If you have money to spend and time to save, there’s a case for outsourcing it. But at minimum, all you really need is a page that says who you are and a way for people to reach you. I used Squarespace, which is about as user-friendly as it gets, and I didn’t overthink the templates. It did what it needed to do. (Check out my essay on practical ways you don’t need to spend big to build your practice!)

Slow, Steady, Save: I transitioned slowly in many respects. I lived at home, saved money, worked a full-time W2 job, and eased into private practice rather than leaping. (Minus that office space I was all too excited to get! Hah!)

I spent a long stretch working community mental health across different settings first, and I credit that stretch directly for the skill and confidence I now have working with crisis and trauma. There’s no version of private practice training that replaces that for me. I wouldn’t dive into private practice right away and I also know many successful clinicians who have.

Life Saving Admin: I hired part-time admin support and let it grow into as-needed help rather than bringing someone on full-time before I actually needed the capacity.

Asking for help: Early and often. I was not afraid to admit if something wasn’t working, if I have no clue what I am doing, and even more unafraid to share this with anyone who would listen in hopes they had some idea or resource to share.

*And even if someone you reach out to is too busy to help directly, they may still be able to point you toward some helpful resources!

Sharing Ideas, Lead with Generosity: And the thing I wish I’d gotten comfortable with sooner, the thing I’m doing now: sharing what I know, publicly.

This newsletter. Instagram. Writing down the things I used to only say out loud to other clinicians in private. It’s become another way to create impact, to put information in front of people who don’t otherwise have access to it—which, if you’ve been reading this far, is probably part of why you’re here.

Where this leaves me

None of this was a plan. I famously tell people that my goal or dream was not to own a group practice. Maybe in some ways, that’s what makes it easier for me to take risks. I am not so focused on capturing a perfect idea of what my practice “should be” which leaves the door open to what it could be.

Success, for me, was a series of expensive lessons, a few decent instincts I got lucky with, and a slow willingness to notice when something wasn’t working and change it—which, it turns out, is more or less the entire skill set Krumboltz was describing forty years ago.

Curiosity got me into the office lease I shouldn’t have signed. Persistence got me out the other side of it. Flexibility is the reason the list above exists at all instead of just a single, permanent version of my practice that never adapted.

You don’t have to predict how your practice will unfold. You have to become someone who notices when it’s telling you something, and takes the risk of listening.

I didn’t know what I was doing when I started. I’m not sure any of us fully do. I think that type of humility can lead to both a humor and openness that is necessary for a sustainable career in this field.

I was simply paying attention, and eventually paying attention is what turned into a business.Thanks for reading Practice Forward! Subscribe for free to receive new posts and support my work.

A resident who shared their time and talent with us at my own group practice, quietly laying the groundwork for something of their own. A colleague from my academia days stepping carefully out on their own, balancing clinical work with teaching, trying to hold both without dropping either. A community member who found me through LinkedIn looking for a little consultation, a little reassurance, a little of the information that nobody had thought to offer them yet.

In every one of those conversations, I’ve tried to be open—about what I know, about what I don’t, about what I wish I’d done differently and what I think actually worked. Because something I’ve noticed, both in my own group practice and in the broader professional community, is that once clinicians become fully licensed, the question starts forming quietly: could I do this on my own?

And I’ve also noticed that not everyone is willing to help them answer it.

There’s a certain closed-offness that exists in some corners of this field—a reluctance to share knowledge, a worry that information is intellectual property, a fear that the clinician you invested so much time and energy developing will eventually become your competition. I want to be transparent: I’ve heard this reasoning directly. I don’t share it, but I think it’s worth naming because it shapes the environment a lot of clinicians are navigating when they start asking these questions.

If you’ve already been through the gauntlet—practicum, internship, supervised hours, licensure—and you’ve landed in a group practice, you already know they are not all created equally. Some are genuinely supportive environments where growth is encouraged and transparency is the norm. Others are not. Most fall somewhere in the complicated middle.

People arrive at this decision from all kinds of places. Some have outgrown the structure—they want autonomy, specialization, the freedom to build something that reflects their own clinical values. Some leave because the math stopped making sense: they’re generating revenue that doesn’t match what they take home, and the gap has become impossible to ignore. Some leave because of culture—a practice that didn’t turn out to be what it promised, a supervision relationship that wasn’t supportive, colleagues they never quite clicked with. And some leave because staying became ethically untenable—they witnessed something they couldn’t unsee, or experienced something they couldn’t move past. For those clinicians, leaving isn’t a career choice so much as a values one, and the transition carries a different kind of weight.

Whatever brought you here, the how of leaving matters as much as the why.

Here’s what most advice about leaving a group practice focuses on: websites, insurance panels, marketing, EHR systems. All of that matters, and we’ll get there. But I think the harder transition is something else entirely. You’re not just leaving employment. You’re becoming the person responsible for the entire container—and that is an identity shift as much as it is a logistical one.

This essay is my attempt to put down, in one place, everything I think is worth considering if you’re in a group practice and you’re at the point—or getting close to the point—of going out on your own. Not as someone who has it all figured out, but as a colleague who has been around long enough to have opinions, has made enough mistakes to have perspective, and thinks you deserve more than vague encouragement and a LinkedIn post about betting on yourself.

Let’s get into it.

Part I: The Transition

This is an Identity Transition, Not Just a Logistical One

Leaving a group practice to open your own isn’t primarily about getting clients or building a website. It’s about moving from clinician identity to owner identity—and those two orientations require genuinely different thinking.

In a group, someone else is holding the business. You’re accountable for your caseload, your notes, your clinical quality. The administrative infrastructure exists around you, often invisibly. You stop noticing it the way you stop noticing the air conditioning until it breaks.

When you leave, you become the person holding all of it. That shift—from operating within a system to building and running one—is where most people get caught off guard. It’s not a reason not to go. It’s a reason to go prepared.

The goal isn’t a perfect launch. It’s a clean one—with your ethics intact, your finances understood, your clients cared for, and your values driving the decisions rather than anxiety.

I’ve written about what that readiness actually looks like—worth reading before you commit to a timeline.

A clinician I know delayed leaving her group practice for almost eight months because she kept waiting to feel certain. She thought certainty was the prerequisite. What she actually needed was a spreadsheet, an attorney consult, and someone to tell her that the uncertainty doesn’t fully resolve—you just get better at making decisions inside of it. She opened her practice, filled her caseload, and later told me the waiting was the hardest part. Not the leaving.

I think about her whenever someone tells me they’re almost ready.

You may already be ready. Let’s find out.

Leave a comment

Part II: The Ethics

Before You Do Anything Else: Read What You Signed

Not just your employment contract. All of it. (I hope you read it before you signed it, to be honest.)

Pull your independent contractor (IC) or employment agreement, any non-compete or non-solicitation language, your insurance contracts, supervision agreements, EHR access terms, sign-on bonus repayment clauses, and any CE reimbursement agreements you accepted. Look specifically for your notice period, client transition expectations, record ownership language, chart access after departure, and tail coverage requirements.

One distinction that matters more than people realize: are you a W2 employee or a 1099? The answer changes your exit procedures significantly. W2 employees typically have HR-facing termination processes—notice periods, benefits continuation timelines, and final paycheck laws that vary by state. Independent contractors are governed more directly by the contract itself. If you’re a W2, review your employer’s termination procedures and any employee handbook before you give notice, not after.

Some of what you find will be standard. Some may surprise you. Either way, knowing before you give notice protects you in ways that knowing after simply cannot.

A Note on Non-Competes, “Poaching,” and the Infrastructure Argument

Some group practices include non-solicitation clauses, client transfer fees, or restrictions on notifying clients of your new location. Some owners defend these arrangements vigorously. The argument usually sounds something like: we invested in the infrastructure that brought these clients to you. That has value.

And—to be fair—it does. Building and sustaining a group practice requires real investment, and the frustration some owners feel when clinicians leave and clients follow isn’t entirely without basis.

But here’s where I land, and I’ll be transparent that this is my perspective:

Clients are not property.

They are people in treatment who formed a relationship with you—your approach, your presence, your clinical style. That doesn’t transfer with a directory listing.

Clients have the right to make their own decisions about their care. A client who chooses to follow you is exercising autonomy. A client who chooses to stay with the group is also exercising autonomy. Both are valid outcomes, and neither requires a transaction fee to honor.

Whether a non-compete is enforceable in your state is a question worth taking seriously—enforceability varies considerably by state and healthcare context, and many restrictions receive closer scrutiny when continuity of care is involved. “Probably unenforceable” isn’t the same as “not a problem,” because navigating it legally costs time, money, and energy. If your agreement contains restrictive language, consult an attorney before you make any moves.

What I’d encourage you to carry into your exit regardless: handle the transition with integrity, document everything, and let the ethics be the floor—not the ceiling.

Leave a comment

How to Take Care of Your Clients During the Transition

Every group practice and supervisor will manage transitions differently—follow whatever you’ve agreed to. But there are general best practices that protect your clients, protect you professionally, and make for a cleaner exit in any circumstance.

Give enough notice in the relationship, not just the calendar. Two weeks might satisfy HR. It doesn’t satisfy the therapeutic relationship. For clients you’ve worked with for a year or more, or who are in active or high-need phases of treatment, more lead time and more conversation is appropriate. The standard worth holding yourself to: did this person have enough time to process this, ask questions, and make a real decision about their next step?

Tell them clearly—in session and in writing. The conversation should happen in session first, with enough time to actually sit with it. Then follow up in writing through your EHR—documenting what was said, what options were offered, and what the client decided. This respects their need to process outside of session and creates a record that protects everyone.

Be honest about where you’re going. If your agreement permits you to tell clients where you’re relocating, tell them. If it doesn’t, consult legal counsel before assuming—ethics codes across disciplines generally support a client’s right to know how to access continued care. What you can almost always do, even under restrictive contracts, is provide a referral list that includes community resources and other clinicians. That is continuity of care, not solicitation.

What to actually say doesn’t require a script, but it does require clarity. Something like: “I want to let you know that I’ll be leaving [practice name] and opening my own practice. My last day here will be [date]. You’re welcome to continue with me at my new practice, or I can connect you with other providers here or in the community. What matters most is that your care doesn’t get disrupted.” Adjust for the relationship and stage of treatment, but keep the core elements: the information, the timeline, the options, and the reassurance.

When a client follows you, their consent forms don’t. The intake paperwork and HIPAA documents they signed at the group practice belong to the group practice. Before you see any client in your new space—virtual or physical—they need to complete your intake process from scratch.

Document every conversation. Who you told, when, what was said, what they decided. If a client is upset, document that and how you responded. Leave every chart in a state that someone else could pick up—closed treatment plans, resolved authorizations, a brief discharge summary where appropriate.

Share

Clarify Who Owns What

In most group practices, the medical record belongs to the practice. The practice responds to subpoenas, handles records requests, and is responsible for retention—not you.

Before you leave, get clarity in writing on what happens when a former client reaches out two years from now, what happens if a complaint is filed and you need to access your own notes, and what happens when someone submits a records request with your name on the chart.

And if you’re planning to transfer any client records to your new practice, ask yourself an equally important question first: do you actually have the infrastructure—legally and ethically—to store them? That means a HIPAA-compliant EHR, business associate agreements with any platforms handling protected health information, and a retention policy that meets your state’s requirements. “I’ll figure it out when I get there” is not a records management plan—and ambiguity in this area doesn’t stay harmless forever.

Part III: The Operations

Decide Your Insurance Model Before You Open

This decision shapes everything else—cash flow, administrative load, credentialing timeline, and how you’ll spend the first several months in practice.

Are you going fully private pay? Insurance-based? Hybrid? Out-of-network only? Temporarily private pay while you credential?

If you’re planning to panel with insurers, your group credentialing does not transfer to you. You’ll need new contracts under your own Tax ID and NPI. Update your CAQH profile to reflect your new practice information before beginning any applications. Credentialing timelines can run two to six months or longer—sometimes more, depending on the payer and state—and the cash flow gap while you wait is real. Build it into your planning.

This piece on what private practice actually requires is worth sitting with before you finalize your model—because the right choice should reflect your financial reality, not just your clinical preference.

Build Your Infrastructure Before Your First Client

Before you see anyone, you need actual systems in place—not just the intention of systems.

That means a legal business structure (LLC, PLLC, or sole proprietorship, depending on your state and liability preferences), an EIN from the IRS, a business bank account entirely separate from your personal finances, and a registered business name if you’re operating under anything other than your legal name.

It means an EHR that handles notes, scheduling, billing, and your client portal. It means HIPAA-compliant phone and telehealth platforms. It means malpractice coverage under your own name, confirmed before your first session.

If you’re seeing clients in a physical space, confirm it meets zoning requirements for healthcare use. If you’re fully telehealth, know which states you’re licensed in and whether your clients can be located there during sessions.

Share

Know Your Survival Number

Before you build anything, know your floor.

What’s the minimum you need monthly to cover your obligations without panic? Not the ideal—the survival number. Then work backward: malpractice, EHR, HIPAA-compliant technology, phone, website, bookkeeping, quarterly taxes. Add personal costs: health insurance, retirement, an emergency fund. Self-employment income is unpredictable in ways W2 income isn’t, and the gap between when you earn and when you pay taxes catches a lot of new practice owners off guard.

Talk to an accountant before your first tax season, not after it surprises you.

You don’t have to spend a lot to build something real—but you do need to know what you actually owe so you’re not making decisions from a place of financial fear.

More on the financial realities that don’t make it into the optimistic version of this conversation—read it if you’ve been avoiding it. And on building without overspending, if startup costs are starting to feel like they’re multiplying.

Private Practice Is Built on Relationships and Reputation

There’s a reason clinicians consistently say their best referral source is word of mouth. The most sustainable practices aren’t always run by the best marketers. They’re run by people others think of when a colleague asks if they know a good therapist.

Visibility doesn’t require a full content strategy. It requires staying on people’s minds—which means staying in contact.

• Before you build anything outward-facing, start with a simple exercise: google yourself right now and see what comes up. Personal photos, old profiles, outdated bios, forgotten accounts—these are first impressions you’re not managing. Clean up anything that doesn’t reflect who you are professionally.

• If you’re going to invest in one thing first, make it a professional photo. Before the website is polished, before the content strategy is figured out—a good headshot does more work than most clinicians realize. It lives on your directory profiles, your website, your Google listing, your LinkedIn. It’s often the first human thing a prospective client sees before they decide whether to reach out.

• Claim your handles next. Even if you’re not ready to actively use every platform, create professional accounts on the outlets that matter—your name or practice name, consistent across LinkedIn, Instagram, Psychology Today, and anywhere else your clients or referral sources might look. Securing the handle costs nothing. Losing it to a naming conflict costs more than you’d think.

• A professional, HIPAA-compliant email address is non-negotiable. Standard consumer email accounts without appropriate safeguards and business associate agreements are not appropriate for clinical communication. I use Google Workspace, which provides a business email under your own domain with a BAA. Get this set up early—it feeds into your website, your intake forms, your directories, and every professional introduction you make.

• A website that clearly communicates who you work with and how is your first introduction to most people who will eventually reach out. Search optimization matters more than most clinicians want to think about, because “therapist in [city] specializing in [population]” is how a lot of clients begin looking. A Google Business profile is free and meaningfully increases local discoverability.

• Social media is worth being strategic about rather than simply present on. The goal isn’t everywhere—it’s somewhere that feels authentic and sustainable, consistent enough to build recognition over time.

  Leave a comment

And then there are the relationships you already have.

If you can leave your group practice on good terms, do it—genuinely. The colleagues you worked alongside, the supervisors who invested in you, the people who sent you referrals: those relationships have professional weight that outlasts any single job. Show up when you can. It costs almost nothing and builds the kind of goodwill that quietly fills caseloads.

I also know that not everyone gets that option. Some clinicians leave not because they’ve outgrown a practice, but because they’ve witnessed something harmful or unethical and staying is no longer something they can do with integrity. If that’s your situation, maintaining contact with that practice may not be appropriate or safe—and I won’t suggest otherwise. What I’d say instead: your cohort is yours. The peers from your training program, the colleagues who came up alongside you, the people in your consultation group—those relationships exist independently of any one practice. Invest in those. They may be the most professionally generative connections you have.

There are other truths about referrals and visibility that don’t always get said—worth a read if you’re in the early building stage.

Account for What the Group Was Quietly Absorbing

In a group practice, there are things you don’t pay for because someone else does: admin support, scheduling coverage, billing staff, peer consultation, referrals, coverage when you’re sick, tech troubleshooting, supervision, community. When you leave, you become responsible for replacing these—or doing without them. And “doing without” has real clinical and personal costs.

If you’re still accruing supervised hours, you need a supervision contract in place before you see clients independently. If you’ve been providing supervision to others, confirm you’re meeting your state’s requirements under your own credentials. Build a CE plan and store your certificates somewhere organized—renewal surprises are avoidable ones.

Build your peer structures deliberately. Consultation groups, trusted colleagues, your own therapy. Solo practice can feel wonderfully free. It can also get very quiet, very fast. The antidote isn’t more productivity—it’s more connection.

Set Your Clinical Policies Before Your First Client

Before you open: your cancellation policy and how you’ll actually enforce it. Your sliding scale philosophy and your floor. Session lengths, communication availability, crisis coverage, vacation policy, telehealth state restrictions.

Develop your emergency protocols before you need them. Who covers when you’re unavailable? What happens when a client is in crisis after hours? What’s your process when someone needs a higher level of care than you can provide?

Clients adapt to the container you create. Make sure it’s one you can actually sustain.

Leave Cleanly

Document everything. Your last clinical date. Every client transition conversation. Referral lists and outcomes. Outstanding claims, pending notes, open authorizations, and unresolved treatment plans.

Your exit needs to survive an audit, a complaint, a subpoena, future confusion. This isn’t paranoia—it’s professionalism. And it’s what protects you years from now when you’ve moved on and something from this chapter resurfaces unexpectedly.

Part IV: The Growth

The Emotional Weight of Leaving

Leaving a practice where you were supported, trained, or genuinely cared about your colleagues isn’t just a logistical event. There’s often real grief in it—guilt, loyalty conflict, fear of being seen as competition, imposter syndrome, and a loss of professional identity you didn’t see coming.

You can appreciate everything a place gave you and still outgrow it. Both can be true at the same time.

The questions underneath the strategy are worth sitting with—not just the tactical ones, but the ones about what kind of work you actually want to be doing and what kind of professional life you’re building.

The early period of practice ownership is a lot of doing and very little being. The comparison to other practices—who seems to be filling faster, who seems to have it more together—is an easy trap and a genuinely useless one. Reconnect with your why regularly. Not as a motivational exercise, but as a grounding one.

And please: therapy for the therapist is not a cliché. It’s one of the more important investments you can make when you’re holding a caseload, running a business, and navigating the emotional complexity of leaving something that shaped your professional identity. You’d tell a client the same thing.

Ask Yourself the Uncomfortable Question

Am I opening a practice—or am I creating a job?

Neither is wrong. But they’re different goals that require different structures—and conflating them is one of the more common ways early practices run into trouble.

A job means you’re doing the clinical work. Revenue depends on your hours. The model scales with you and only with you. That can be exactly what you want—autonomy, clinical depth, a caseload you’ve curated, no management responsibility. There is nothing small about that vision.

A practice means something else. It means systems that exist independent of your availability. It means eventually asking yourself questions like: Do I want to supervise other clinicians? Do I want employees, or contractors, or both? Am I prepared for payroll, for HR conversations, for the weight of someone else’s livelihood being partially in my hands? Do I want to build something I could someday step back from—or do I want to be deeply embedded in the clinical work for the long term?

These aren’t rhetorical questions. They have real answers that should shape how you price your services, whether you hire admin support, how you structure your space, what your insurance panel strategy looks like, and whether the word “expansion” excites you or makes you want to close a tab.

You have context here that most business advisors don’t: you’ve lived inside a group practice. You’ve seen what that structure asks of the person running it. Let that inform your decision—not as a deterrent, but as data.

Knowing which one you’re building is worth deciding before the caseload makes the decision for you.

What Happens If This Works?

Most transition planning focuses on risk: what if I can’t fill my caseload, what if credentialing takes forever, what if I run out of runway. Those are real and worth planning for.

But success has its own complications. A growing waitlist. Referrals you can’t take. Burnout from running a full caseload while also running a business. The moment someone asks if you’re hiring and you realize you don’t actually know what that would look like for you.

Planning for growth isn’t hubris. It’s just completing the picture.

Here’s the hot take, though: I think a lot of clinicians are more afraid of success than failure.

Failure is familiar territory—we have frameworks for it. We know how to sit with disappointment, how to regroup, how to try again. But success? Success means visibility. And visibility means being seen, assessed, and potentially judged. It means someone noticing that your practice is full, that you’re charging what you’re worth, that you’ve built something. And for a profession that trains people to stay in the background—to be the witness, not the subject—that kind of exposure can feel deeply uncomfortable.

This shows up as reluctance to market yourself, hesitation to raise your fees, apologizing for your rates before anyone has even asked, downplaying what you’ve built in professional conversations, deflecting compliments about your practice with “I’ve just been lucky.”

It also shows up as self-sabotage that’s harder to name: staying smaller than your capacity, underpricing indefinitely, avoiding the visibility that would actually bring in the clients you want.

There is nothing ethically compromised about being good at what you do and letting people know it.

Wanting your practice to succeed is not the same as being self-aggrandizing. Building visibility is not the same as being boastful. Charging appropriately is not the same as being greedy. These conflations are worth examining—because if you carry them unchecked into practice ownership, they will quietly put a ceiling on everything you’re trying to build.

Share

One Last Thing

The transition from clinician to owner isn’t a one-time shift. It’s a sustained reorientation—and it takes longer than the paperwork does.

Give yourself permission to not have it figured out on day one. Give yourself permission to build slowly, to ask questions, to not perform certainty you don’t yet feel.

You do not have to become less of a therapist to become an owner. You may simply need to become more of yourself.

Both framings get something important wrong.

Sliding scale and pro bono work aren’t about generosity—or at least, they shouldn’t be structured that way. When we operate from a generosity frame, we make decisions based on feeling rather than sustainability. We say yes without a system. We absorb the cost in ways we don’t fully account for. And eventually, something gives.

This essay is about building that structure—before you say yes, and long after.

What the ethics codes say—and what they leave out

Most of the major professional ethics codes gesture toward access, though what they actually require varies more than the sliding scale discourse tends to acknowledge.

The ACA Code of Ethics identifies social justice and respect for diversity as foundational professional values. While it does not require counselors to offer pro bono or reduced-fee services, it does encourage attention to access, equity, and barriers to care. The value is aspirational; the implementation is yours to design.

The APA Ethics Code frames psychologists’ responsibilities through principles such as beneficence, nonmaleficence, and justice. Although it does not prescribe specific fee structures or pro bono expectations, it supports consideration of equitable access and the fair distribution of psychological services—more of a professional orientation than a practice directive.

NASW is perhaps the most explicit in linking practice to social welfare and social justice. While the code stops short of requiring pro bono care, it places access and equitable service delivery near the center of professional identity in a way the other codes don’t quite match.

What none of them tell you: how.

They don’t tell you how many reduced-fee slots is reasonable for a solo practice with specific overhead. They don’t tell you what to do when a client’s financial situation changes mid-treatment. They don’t address what it does to the therapeutic relationship when a client knows they’re your lowest-paying client—and feels it, even if neither of you names it.

The codes tell you what to aspire to. The rest is yours to figure out.

Leave a comment

The models: more than one way to do this

There’s no single right way to structure reduced-fee work, and the model you choose should fit your practice, your values, and your clinical style.

• Traditional sliding scale. You establish a fee range and clients self-report income and household size to determine where they land. The therapist typically holds the decision-making power—either explicitly, reviewing what clients share and assigning a rate, or implicitly, giving a range and trusting clients to place themselves honestly. This model is common and reasonably straightforward to administer, but it puts the burden of disclosure on the client and the burden of judgment—and potential skepticism—on you.

• Equitable or community care pricing. A growing number of practitioners are moving toward a model that decentralizes the assessment entirely. Rather than asking for income verification or making rate decisions on behalf of the client, you offer a self-guided tool so clients can locate themselves on the scale.

What that looks like in practice is below. It’s worth sitting with yourself before you offer it to a client. The questions have a way of landing differently when you’re the one answering them.

Community Care Pricing: A Self-Assessment

A note before you start: this assessment isn’t about your current income. It’s about financial stability, access, and cushion—the broader picture of what economic security has looked and felt like for you. Some of these questions reach into your past. That’s intentional. Answer honestly, not aspirationally.

1. Could you cover an unexpected expense of $1,000 or more without going into debt, depleting your savings, or asking someone for help?

2. Do you own property—a home, land, or investments—or does your family?

3. If you lost your primary income tomorrow, do you have people in your life who could support you financially, at least temporarily?

4. Have you been able to access healthcare—medical and mental health—when you’ve needed it, without significant financial hardship?

5. Is debt a manageable or minor factor in your financial life, rather than something that shapes your daily decisions?

6. Have you had a reliable income source over the past few years, without significant gaps due to job loss, illness, or caregiving responsibilities?

7. Do you hold a college or graduate degree—or could you have pursued one, if you’d chosen to?

8. Does your income support only you, rather than children, aging parents, or others who depend on you financially?

9. Have you inherited—or do you expect to inherit—money, property, or other significant assets?

10. Has your citizenship or documentation status generally opened doors for you rather than closed them—in employment, benefits, or financial access?

11. Growing up, would you describe your family’s financial circumstances as stable, comfortable, or secure—even if your situation looks different now?

12. Do you have retirement savings or financial assets beyond what’s in a checking account?

More no than yes → Solidarity Rate More yes than no → Market Rate Almost all yes → Community Care Rate (above standard, contributing to access for others)

If some of these feel hard to answer—or if your situation is genuinely mixed—that’s worth sitting with. The goal isn’t a perfect score. It’s an honest one.

Share

This model redistributes decision-making power back to the client and removes you from the position of arbiter. It also invites clients with means to actively contribute to the access ecosystem rather than passively paying whatever you’ve set. The tradeoff is that it requires trust—and asks clients to reflect honestly, which isn’t guaranteed. But it mirrors something true: people know their financial lives better than we do, even when presenting income doesn’t capture the full picture.

Pro bono. Full reduced or no-cost services, typically offered for a defined period or in a limited number of slots, often to clients who genuinely cannot access care otherwise. Some clinicians maintain one or two pro bono spots as a standing practice commitment. Others offer it situationally—when a client’s financial circumstances shift dramatically mid-treatment, or when the clinical stakes of premature termination feel significant.

Each of these models has clinical and relational implications that are better worked out before you’re in the middle of a first session trying to improvise what you believe.

Before you say yes: the questions to answer first

One thing to be direct about before we get into structure: taking insurance is not the same as offering a sliding scale, even though it’s easy to arrive at that assumption.

Insurance reimbursement rates are already discounted—sometimes significantly below private pay. And the administrative labor required to panel, credential, file claims accurately, manage denials, and navigate prior authorizations represents real unpaid work that gets absorbed into the practice. That labor is not nothing. It’s one of the reasons therapists feel the weight of insurance participation in ways that aren’t fully visible on a per-session basis.

But insurance is a business arrangement. Sliding scale is a fee accommodation—a direct, negotiated shift in what a specific client pays you for a specific period of time. They’re doing different things, and they don’t substitute for each other. A paneled therapist serving insured clients and a private-pay therapist with four reduced-fee slots are both making access-oriented decisions. Neither arrangement automatically covers the ground the other leaves open.

If you’re still working out what insurance participation actually costs your practice—and whether the access argument holds up against the full picture—Welcome to the Upside Down is a good place to start.

Before you build the structure, sit with these:

• Is this decision coming from genuine capacity—or from guilt? The two can feel similar from the inside, and they tend to produce very different arrangements.

• Do you have a specific number of slots in mind, or are you effectively saying yes to whoever asks?

• What does your current caseload look like in terms of clinical complexity and demand? Is this actually a good moment to add cases that may require more of you?

• When those slots are full, can you say so clearly—without over-explaining or apologizing?

• What would you do if a client in a reduced-fee arrangement couldn’t meet even that rate? Do you have a plan?

• Are you in a financially stable enough place in your practice that resentment isn’t a realistic risk?

• Have you talked this through with anyone—a consultant, peer, or colleague—or are you making this decision in isolation?

None of these are meant to talk you out of it. They’re meant to make sure you’re building something that holds.

Share Practice Forward

How many reduced-fee clients can your practice realistically sustain? Part of this is arithmetic: what does your overhead cost each month, what’s your current income, and what would a meaningful reduction in average session rate mean across a full year? If you’re insurance-paneled, you’re already accepting rates below your private pay fee. That’s part of the math too.

But two clinicians with identical numbers may make very different decisions—because one prioritizes community access while another prioritizes practice expansion, additional supervision, or family stability. Sustainability is arithmetic informed by values.

A sustainable number of reduced-fee spots is something you can name before a client asks. Two slots. Four. Whatever it is. When those slots are full, they’re full—not because you’re unkind, but because you have a practice to maintain. Scarcity is not indifference.

Per session or Circumstance

You’ll also want to decide whether your sliding scale is assessed per session or tied to a qualifying set of circumstances. Per-session arrangements—where clients pay what they can each week—create recurring financial conversations that can become clinically burdensome. Qualification-based arrangements, where a rate is set based on the client’s current financial picture and holds for a defined period, tend to be cleaner to manage. Most practitioners find the latter more sustainable, and it makes the money conversation a bounded event rather than a standing agenda item.

One practical note: if you’re paneled with insurance, review your payer contracts before implementing reduced-fee arrangements for insured clients. Some contracts include provisions around collecting copays, waiving cost-sharing, or offering discounts that could affect compliance. Sliding scale decisions are generally cleaner with private-pay arrangements, but policies vary—and better to know before you implement than after.

Leave a comment

The agreement: structure is a clinical tool

Once you’ve made the decision to offer a reduced fee, you need a document. Not because you don’t trust the client—but because clarity protects the relationship.

A solid sliding scale agreement covers: the agreed-upon rate and how it was determined, the duration of that arrangement, what would prompt an earlier review, expectations around communication if the client struggles to meet even the reduced rate, and how the conversation about adjusting or ending the arrangement will happen.

That last piece matters more than it looks like it should. What happens when a client’s circumstances improve and you need to have the money conversation again? Having the framework established at the outset means you’re not inventing a protocol in the middle of a charged moment.

A full sample agreement is included at the end of this piece. Use it as a starting point—your language and clinical context should shape it.

Review and renewal: building it in

A reduced-fee arrangement without a built-in review process quietly becomes permanent by default. That’s not sustainable for your practice, and it’s not necessarily in the client’s best interest either.

Build the review into the agreement from the start. Something like: We’ll revisit this arrangement at six months and assess whether the current rate still fits your circumstances and my practice capacity. When it’s framed as mutual and scheduled rather than reactive, it becomes part of the treatment frame—not a confrontation.

The six-month check-in doesn’t have to be a formal audit. It can be as simple as: We talked about revisiting your fee arrangement around this time. Has anything shifted for you financially? A client whose situation has improved may feel relief at being asked. A client whose situation has worsened may need more flexibility than the original agreement anticipated. Either way, the conversation belongs in the room.

What you want to avoid is the slow drift—where the arrangement is never revisited, you’ve stopped tracking whether it still makes sense, and the clinical relationship is quietly shaped by a financial dynamic neither of you is naming.

Share

What changes in the room

This is the part most discussions of sliding scale skip.

The money arrangement is a relational variable. It affects what clients feel, what you feel, and what moves between you.

For Clients

For clients, knowing they’re receiving a reduced fee can activate any number of things: gratitude that tips into deference, guilt that interferes with their ability to claim space, a sense of obligation that makes rupture or confrontation feel dangerous. Some clients under-function in treatment—don’t cancel, don’t push back, don’t advocate for themselves—because they don’t feel entitled to take up space at a rate they didn’t fully earn. That pattern deserves clinical attention.

For You

For you, reduced-fee work can shift in ways that aren’t always easy to name. Some clinicians notice they work harder with clients they’re charging less—over-preparing, running long, over-investing—as if to compensate. Some notice the opposite: a subtle, unexamined erosion of engagement when the fee doesn’t feel commensurate with the clinical lift.

For The Process

And then there’s something quieter: reduced-fee arrangements can sometimes invite a rescue dynamic that doesn’t announce itself as such. The therapist becomes helper, protector, safety net—in ways that exceed treatment goals. Not because the clinician lacks boundaries, but because financial accommodation can subtly shift identity and role. The work starts to feel like it means more than other cases. That shift deserves attention.

There’s a broader layer here that doesn’t resolve cleanly.

Sliding scale is often framed as a way of leveling the playing field, and in some real ways it is. Reducing financial barriers to care, meeting clients where they are economically, signaling that their treatment matters beyond their ability to pay—these things carry genuine relational and even political weight, particularly for clients who have historically been priced out of mental health care or who carry internalized messages about being too much of a burden to deserve it.

But sliding scale also contains its own power dynamics, and the critique is real.

The therapist still controls who gets access to reduced-fee spots, who qualifies, when they’re full, and how the assessment works. That’s a meaningful concentration of resource-holding power—even when it’s exercised with care. The client who receives a reduced fee has been granted something by the person they’re also supposed to be honest with, disagree with, and occasionally rupture with. That’s a complicated position to be in. The client who pays more under a community care model to fund access for others is in a different but equally interesting one.

The equitable pricing self-assessment model redistributes some of this by returning the decision to the client—but it also asks them to accurately evaluate their own class position and privilege, which is a sophisticated reflective task that bumps up against denial, shame, and blind spots just like any other.

That complexity doesn’t disqualify the work. It means the power structure inside it deserves the same rigor you’d bring to any other relational dynamic—what does it mean to be the person who holds the resource? What does it activate in you when you’re in that position? What might it activate in your client, and have you made space for that material to surface?

These are supervision questions. They’re also just good clinical questions—and they belong in consultation, peer support, or wherever you have space to think about the work out loud.

On limits—and what they actually mean

Reduced-fee work is good practice when it’s structured, sustainable, and reflected upon through consultation, supervision, peer support, or intentional self-review.

It becomes a slow drain when it’s guilt-driven, boundary-less, and invisible in your own accounting.

You can hold a genuine commitment to equitable access and also hold limits on what your practice can absorb. You can care about what’s happening in the healthcare system and decline to personally finance its failures. These aren’t in conflict—they’re both just true.

If you have the capacity: build it in before a client asks, not in response to one who does.

And if your practice isn’t there yet—if you’re still building toward financial stability, if your caseload is already carrying a lot, if your own nervous system is in the equation—that’s a legitimate answer too. The ethics codes use the language if able for a reason.

Access work done at your own expense, without limits, without anyone asking how it’s sitting with you—that’s something else entirely.

Without the structure, it slides back into the frame we started with. And you already know where that goes.

Edit: July 9th: Oh, you know…that moment when you say there is an attachment and there isn’t one…

Sliding Scale Fee Agreement Template.

The range in the room was real. Some clinicians came in reluctant, protective of something they’d worked hard to build. Others were proudly boundaried around social media and had no interest in reconsidering. A few were leaning in—creating content for their group practices, curious about what a brand could actually look like for them.

Nobody had clean answers. That conversation stayed with me.

So did the obvious next call. I knew I needed to think this through with someone who has lived it from the inside—my friend and fellow therapist Jazzmyn Proctor, host of The Visibility Standard, a podcast helping therapists develop the mindset and strategy to show up as their authentic selves on and offline. Her perspective is woven throughout what follows. You can also catch Jazzmyn on IG!

Subscribe now

Somewhere in the last several years, the mental health field developed a parallel credentialing system.

It didn’t announce itself. It didn’t require a licensing board, a supervisor’s signature, or a single supervised hour. It runs through Instagram, TikTok, LinkedIn, and Substack, and it measures authority in followers, shares, and saves. And whether we’ve named it yet or not, it is functioning—out here in public—as a legitimate system for deciding who gets to be trusted.

That’s what we keep coming back to. Not that social media exists, or that people use it to learn about mental health, or even that some of what gets posted is clinically imprecise. All of that is true and also somewhat beside the point. The more unsettling thing is this: the field hasn’t decided what to do with the fact that a parallel legitimacy system is already operating. And the people most qualified to weigh in are, in many cases, the ones least present in the conversation.

We want to think through that carefully. Because we don’t think the clean critique holds.

There’s a shorthand we were all trained to read.

The name. The degree. The letters that follow—LPC, LCSW, PhD, LMFT. The certifications stacked underneath: EMDR trained, DBT certified, IFS Level 2. The university affiliation. The supervised hours logged. The years. We know what that alphabet soup means because we earned our own version of it. And if you’re honest, you probably remember the exact moment yours started to feel like proof of something—proof that you belonged here, that the gatekeepers had seen you and nodded, that the expensive, slow, emotionally demanding process of becoming licensed had converted into something real.

What social media has quietly surfaced is something the field doesn’t always say plainly: attunement, presence, and consistency—the qualities that actually move people—don’t have a credential attached to them. You can’t certify warmth. You can’t license the ability to show up reliably, in a voice that sounds like someone’s internal monologue on a better day. The platform didn’t invent those qualities. It just made them visible in a way the traditional system never did.

That doesn’t make the credential irrelevant. But it does complicate what the field has been telling itself about what authority is made of.

And now here we are, watching someone explain the fawn response in a forty-five second video to three hundred thousand people, trying to figure out what we’re supposed to do with that.

Why we trust the followed

The most basic answer is social proof. We are wired, in the most literal neurological sense, to use other people’s behavior as information about what’s safe and worth our attention. If a hundred thousand people follow someone, that registers—beneath conscious reasoning—as evidence that those people found something credible there. The number functions as a crowd. And crowds, historically, were a reasonable signal.

What the platform has done is automate that signal in a way that completely decouples it from its original function. A following isn’t a crowd of people who have vetted someone’s clinical competence. It’s a crowd of people who found their content compelling. Those are different things. But they produce the same shortcut.

Then there’s the parasocial piece—and this one is specific to mental health content in a way that deserves its own attention. When you watch someone on camera, consistently, over time, talking about emotional experience in a warm and personal register, your brain processes that as relationship. Not consciously—consciously you know you’re watching a video. But something in the way we’re built doesn’t fully distinguish between a real interaction and a well-simulated one. You start to feel like you know this person. You start to feel known by them, even though they have no idea you exist.

Think about the way people talk about comfort shows—the series they return to not because they haven’t seen it, but because the familiar rhythms settle something. A creator who has occupied your phone for two years functions similarly. They become a consistent presence, a reliable voice, something that meets you where you are without requiring anything in return. That isn’t a manipulation. It’s something people genuinely need, and the platform is delivering it in a form the formal system rarely has.

That feeling of being known is extraordinarily powerful in a mental health context. It’s close to what people are often looking for when they seek therapy in the first place.

A creator who has spent two years showing up in your phone, talking about anxiety in language that sounds like your own internal monologue, has built something that feels like a relationship. A licensed clinician you’ve never met, with a modest web presence and a list of credentials you’d have to Google, has not. The algorithm has done years of rapport-building on the creator’s behalf. That’s not nothing. It’s also not the same as clinical trustworthiness.

Social media didn’t eliminate authority. It changed what authority looks like—and who becomes legible to the public searching for help at eleven o’clock on a Tuesday night.

• When you find yourself trusting a mental health voice online—what are you actually responding to?

• The credential, the warmth, the consistency?

• Something you can’t fully name? That answer might tell you more than you expect about what the people we serve are navigating too.

Share

When the credential itself became suspicious

There’s a reason this is happening now specifically, and the analysis gets shallower if we don’t say it plainly.

We are in a significant moment of anti-institutional sentiment. Formal, credentialed expertise is under suspicion in a way that feels different from a decade ago—and not just in mental health. The doctor, the scientist, the academic, the licensed professional have all lost cultural authority in ways that didn’t happen randomly. They happened in a context of very public institutional failures, of experts who turned out to be wrong, of systems that turned out to be serving interests other than the public’s.

What’s worth sitting with is not just that institutions failed. It’s that the credential itself has become, for a meaningful portion of the public, a mild red flag. A signal that this person might be captured by the institution, might speak in jargon, might not understand what it’s actually like to be you. Increasingly, people seem to want evidence of humanity before they decide expertise matters. That’s a significant shift—and before we dismiss it, we should probably ask what we did to earn it.

Hold that alongside something more specific and more historically grounded.

The distrust of mental health and medical systems among Black, Indigenous, and other communities of color is not a cultural quirk. It is a rational response to a documented history. Psychiatry has been used as a tool of social control. Black patients have been systematically under-treated for pain and disproportionately diagnosed with conditions like schizophrenia. Indigenous communities have experienced forced institutionalization. The DSM has pathologized identities. Therapeutic frameworks, by and large, were built on white, Western, middle-class assumptions about what a self is, what health looks like, and how healing works.

When someone from one of those communities encounters a mental health creator who shares their background, speaks their language—literally or culturally—and offers insight that actually maps onto their experience, that isn’t just a preference for relatability. That’s finding a point of entry into a system that has, for generations, communicated: we are not built for you.

And crucially, social media offers something a Psychology Today profile cannot. It offers a free, low-stakes, ongoing way to evaluate whether this person is actually who they claim to be. You can watch someone for six months before you book a consultation. You can see how they think, how they handle pushback, whether their values hold under pressure. You can decide—on your own terms, your own timeline—whether this is someone you might trust with something real.

What that dynamic does to the person being watched is less often discussed. Content doesn’t expire. A video posted two years ago can surface in someone’s feed today and become the reason they reach out. A podcast episode recorded in an entirely different season of your practice can land with someone who needed exactly that voice at exactly that moment. The accumulation is asynchronous in a way the formal referral system never was—reaching, resonating, doing work you can’t track and didn’t plan.

For communities that have every reason to be careful about who they let in, the ability to evaluate someone before committing anything is not a small thing. That’s access. And the formal system hasn’t offered it.

So the creator with the following isn’t always just winning a visibility contest. In some cases they are genuinely providing a point of entry that the credentialed system failed to create. That matters, and it should complicate any clean critique of what’s happening here.

Is lived experience enough?

We want to handle this carefully—because there’s a version of this argument that slides easily into gatekeeping. Into licensed clinicians closing ranks around a credential with its own history of exclusion.

So let’s be specific about what we’re actually saying.

Lived experience offers a connection point that training can approximate but rarely fully replicates. It allows for a kind of recognition that can crack open the work in ways that technique alone cannot. The clinicians we most respect are almost always people who have done their own work, who bring a self that has been genuinely tested into the room. That changes the quality of the encounter in ways that are real and not easily taught.

But there’s a distinction that matters and doesn’t always get named. Lived experience as a bridge is different from lived experience as the map. One says: I’ve been in territory like this, I recognize the terrain, let me walk alongside you. The other says: because I made it through, I know the route. The first invites; the second, without meaning to, can close things off.

In therapy, we’re not there to offer our experience as the map. We’re there to help someone navigate theirs. That requires knowing what to do when navigation goes wrong—when someone decompensates, when a disclosure opens something that can’t be easily closed, when the session surfaces something unexpected and there are eight minutes left. Lived experience alone doesn’t prepare you for that moment.

When lived experience gets packaged as a credential without that distinction being named, the people most likely to be harmed are often the people who most need the protections that professional oversight—however imperfect—exists to provide.

• When you share your own story in a clinical or professional context, are you offering it as a bridge or as the map? Those function differently—for the person receiving it and for you.

Subscribe now

What the platform still can’t do

The algorithm doesn’t care whether you’re clinically accurate. It cares whether you’re compelling.

Content that oversimplifies gets shared because it’s satisfying. Content that holds complexity gets scrolled past because it asks too much. The viral mental health post and the responsible one are frequently in direct tension—and the platform consistently rewards the first.

It’s also worth pushing back on the way this discourse tends to flatten into a binary: licensed clinicians on one side, coaches and wellness personalities on the other. That’s not the actual landscape. Social media has created space for associate therapists, graduate students, and clinicians mid-credentialing to build authority and demonstrate expertise in real time—people who have completed their degrees, passed their exams, and are practicing under supervision but don’t yet carry the full credential stack. The conversation is considerably more textured than its loudest versions suggest, and collapsing it into two camps misses a lot of people doing thoughtful work.

The public, largely, cannot tell the difference between a licensed clinician with twenty years of experience and a charismatic person who had a transformative therapy experience and decided to share it publicly. The visual language of both is identical. The warmth and relatability—the thing people actually use to assess trustworthiness—can be indistinguishable.

The recent scrutiny around Cheyenne Bryant is instructive here—not as a verdict on her specifically, but as an illustration of something structural. The public debate collapsed three entirely separate questions: Does this person hold a doctorate? Are they licensed? Are they a psychologist? Those are not interchangeable. They describe different credentials, different scopes of practice, different accountability mechanisms. But on a platform where someone presents warmly, speaks with authority, and has built a substantial following, those distinctions get flattened into a single impression: this person is an expert. When that impression turns out to be more complicated than it appeared, the audience doesn’t just feel misled about a credential. They feel misled about something more fundamental. And the platform that built the trust bears none of the responsibility for its collapse.

One of the things licensure provides—imperfectly, with all its structural problems intact—is a place to go when harm occurs. A licensing board. An ethics process. A mechanism that can be appealed to. A large following provides none of that. The accountability for someone with a hundred thousand followers and no clinical license is essentially reputational—which means it depends on the same platform logic that elevated them in the first place.

And it’s worth saying plainly: the credential doesn’t immunize anyone against harm. Licensed professionals cause harm too. The ethics codes and governing bodies exist precisely because the license was never designed to be the only safeguard. What happens when a licensed clinician’s platform outgrows the architecture designed to hold it—that’s a different kind of cautionary tale, and we’ll come to it.

The ethical questions here are no longer hypothetical. They’re surfacing in real professional conversations about what it means to offer mental health guidance without licensure, about what liability looks like in parasocial therapeutic relationships, about what happens when a creator’s following extends into coaching or courses or retreats that operate just adjacent to clinical work without any of its structures.

Leave a comment

Who owns the wellness space, anyway

Here’s the claim we want to make slowly, because it reframes everything that came before it.

We sometimes talk about social media as if it allowed unqualified people into a space that once belonged to clinicians. As if there was a well-tended clinical garden, and then the fence came down, and now anyone can walk in.

But the self-help industry was never a clinically controlled environment. It was never ours. Therapy existed beside it—not above it, not in charge of it.

Tony Robbins has been walking on fire and charging people thousands of dollars for it since before many of us had our licenses. Gwyneth Paltrow built a nine-figure wellness company around, among other things, a jade egg. Celebrities publish memoirs about their healing journeys and those memoirs outsell every peer-reviewed study written on the same topic. Successful people—entrepreneurs, athletes, influencers—talk openly about their therapists, their coaches, their plant medicine experiences, and in doing so they shape what mental wellness means to the public more effectively than any licensing board ever has.

The self-help industrial complex has always had extraordinarily low barriers to entry. What’s new is that it now has a distribution system—the algorithm—that gives individual creators access to audiences that once required a publisher or a publicist to reach.

So when licensed clinicians say I’m creating content because people without credentials are out there doing it anyway—and we hear this a lot—we understand the impulse. But underneath the public health argument there’s sometimes something more reactive: a professional anxiety about losing ground in a space the field never fully occupied to begin with.

Which raises the harder question. Not should therapists be on social media but what does showing up here actually mean, and for whom?

The metrics the wellness space uses to measure success are not the metrics clinical work uses. A book deal, a speaking fee, a podcast ranking, a sold-out retreat—these measure reach, revenue, and resonance. They do not measure clinical outcomes, accuracy, or whether the person in your comment section actually got better. When clinicians absorb those metrics as measures of their own professional value, something shifts. Not immediately. Not dramatically. But the version of success the platform rewards and the version the therapy room requires are not naturally aligned. The longer you optimize for one, the easier it becomes to quietly stop noticing the other.

The case of Jeff Guenther—Therapy Jeff, LPC—is worth examining here, because it doesn’t fit the easy narrative. His controversy wasn’t about credentials or licensure. It was about a post that many felt misapplied a clinical framework in a way that centered a potential perpetrator’s internal experience rather than survivors. He issued a public apology, said explicitly he had moved outside his scope, and acknowledged a second post that crossed a line inconsistent with the trust his audience placed in him. He has also said openly that nothing in his graduate training prepared him for the dynamics of having millions of followers.

That’s not a story about bad character. And it’s not a story about the absence of a credential—the credential was there. It’s a story about what happens when someone is simultaneously clinician, educator, influencer, and parasocial figure to an enormous audience, and the roles stop being separable. The reckoning, when it came, unfolded through comments and social pressure. Not through any professional channel. The credential is a floor, not a ceiling. And the floor doesn’t hold without something underneath it.

Subscribe now

The grief part nobody talks about

There’s something underneath all of this that we’re too professional to name, so we’re going to name it.

There is real grief in watching this happen.

Not the ego-driven kind—though that’s human too and we can give ourselves permission to notice it. We mean the deeper kind. The kind that comes from having spent years in graduate school, in supervision, in your own therapy, sitting with hard cases, consulting on harder ones, building genuine skill through genuine failure—and then watching a graphic that says “10 signs you have childhood trauma” get 1.2 million views in a week.

It hurts not because we think we deserve the platform. It hurts because somewhere in our training we absorbed the belief that competence would be enough. That if you did the work—really did it—the work would speak for itself.

Here’s a reframe we keep returning to: maybe that’s still true. Maybe the attention economy, in its chaotic way, is actually giving clinicians something the old system didn’t—permission for their specific expertise to find the people who need exactly that. Not mass legibility, but genuine fit. Not a credential stack that signals generic authority, but a presence that says this particular thing I do, for the person who needs this particular thing. There’s a version of showing up that isn’t about measuring up.

The grief still makes sense. Unexamined, it has a way of curdling into something less useful. Into defensiveness. Into contempt for creators doing something different from what we do. Into a posture of professional superiority that doesn’t actually serve the field or the people in it. But examined, it might clarify what you actually want—and whether the attention economy is even the right place to look for it.

• What specifically is the loss you feel when you watch this landscape? Being precise about that—really precise—might tell you something about what you’re still holding onto.

We moved from expertise markets to attention markets

The traditional professional model ran like this: training, licensure, referrals, practice. Authority was conferred by the institution, transferred through the credential, exercised in the room.

What’s emerging looks like this: training, licensure, content, visibility, referrals, monetization. The credential still matters—but it no longer functions as the primary currency for reaching people who need your services. Attention does. And attention has to be earned through a skill set that isn’t taught in graduate programs, isn’t supervised, and isn’t evaluated by any licensing board.

Therapists are now operating inside an attention economy whether they chose to enter it or not. The choice isn’t between participating and not participating. It’s between participating intentionally and having the absence make the choice for you.

Share

What it actually costs to build a presence

Let’s be honest about what content creation actually looks like for most clinicians.

You spend an evening drafting a post. You rewrite it three times, agonize over whether it sounds like you or like a template you’ve absorbed from watching others. You post it. Twelve likes. Your colleague who posted a quote graphic got four hundred. And then you go see clients the next day—behind, distracted, quietly second-guessing whether you’re doing this wrong.

But here’s what the cost-only framing misses.

Before social media, therapists who wanted to reach beyond their immediate geography had two options: the conference circuit, or the slow local accumulation of referrals. Clinical expertise lived largely inside the consulting room and the occasional published article. The platforms—whatever you think of them—have opened rooms that didn’t previously exist. Book deals. Invited speaking. Collaboration with practitioners you’d never have found otherwise. Community that isn’t bounded by geography or specialty or who happened to attend the same training program. Caseloads built not through a single directory listing but through months of consistent presence that compound in ways that aren’t linear and aren’t predictable.

The payoff isn’t immediate, and that can be genuinely hard to reckon with. Clinicians are trained to see results within a fifty-minute frame, in a relationship with a beginning and an arc. Content doesn’t work that way. Something you made on a random Thursday might bring someone to your practice eighteen months from now. The accumulation is asynchronous in a way that can feel like nothing is happening right up until it does.

Content does not automatically become clients. Visibility does not automatically become revenue. A post that performs well may bring followers who are genuinely interested in mental health content and have no intention of entering therapy, cannot afford your rate, or live in a state where you’re not licensed. Following is not a waitlist.

And the time spent building that following came from somewhere—from rest, from consultation, from the parts of your practice that don’t have a content strategy but quietly keep everything functional.

There’s also something worth watching in how content creation can reshape clinical thinking over time. When you’re developing a public voice, you’re selecting for ideas that translate, that can be said in a paragraph, that resolve cleanly enough to share. That’s fine for content. It can be corrosive for the clinical mind, which depends on holding complexity, tolerating not-knowing, and resisting tidy resolution.

If you notice yourself starting to think about your cases in terms of how they’d land as a post, that’s a signal worth taking seriously.

Before you decide what to post, get genuinely clear on what you’re posting for—not what you’re hoping will happen, but what it’s actually in service of. Conflating those is how clinicians end up six months into a content calendar feeling depleted and still not entirely sure why.

The clinician who doesn’t want to be a creator

What about the clinician who got into this work to do the work?

The one who sees clients four days a week, consults carefully, tends their own interior life with real intention—and closes the laptop at six and does not want to think about work until morning. Who has built, deliberately, a practice that doesn’t follow them home. Who finds the idea of turning their clinical thinking into content not just unappealing but contrary to how they understand the work.

These clinicians exist. Many of them are extraordinarily good at what they do. And the current landscape is penalizing them—not always financially, but in terms of visibility and the ability to shape public understanding of what this work actually is.

If the measure is clinical integrity, present-moment availability, and a practice that doesn’t require performing expertise online to justify the rates—they’re doing well. There is something genuinely protective about not having your professional identity mediated by engagement metrics. The clinician who isn’t checking analytics on Sunday night is probably going into Monday with more of themselves intact.

If the measure is whether their voice is part of the public conversation about mental health—they are largely absent from it.

One thing the non-creator clinician does have, increasingly, is access to a referral network that didn’t exist before. Social media allows practitioners to build real relationships with colleagues across the country, across specialties, across practice models—colleagues they’ve actually watched think, whose values they’ve actually observed. When a client moves or needs something outside your scope, you’re not handing them a directory listing. You’re connecting them to someone you know. That’s a form of care that extends the work well beyond the room, and it’s available to clinicians who have no interest in posting anything.

We trained clinicians to protect the therapeutic frame above almost everything, to hold careful limits around their public self, to let the work speak rather than the personal brand. Then the culture moved. And that same careful professionalism now reads, to the algorithm and to the person searching for a therapist on a Tuesday night, as not existing.

That is not a failure of the clinician. It is a problem the field has not adequately named. Asking every clinician to become a content creator to remain professionally viable is asking something significant—and the people least inclined to do it are often, in our experience, some of the most grounded practitioners in the room.

Who will shape what comes next

We may be entering a moment that requires two forms of competence from clinicians who want to remain part of the public conversation: clinical competence, and the ability to translate the complexity of this work into something accessible without flattening it into something false.

Not because followers make you a better clinician—they don’t. But because the public increasingly encounters mental health before they ever encounter therapy. They form their understanding of what therapy is, what it can do, who it’s for, and whether it’s trustworthy through content, through creators, through whatever voices showed up and stayed consistent.

And if we’re being honest about where this is heading—the next iteration of this question may not involve human creators at all. It may be algorithms speaking in therapeutic language, with no followers, no face, no credentials, and no professional oversight of any kind. The parasocial relationship, which at least involves a human on the other end, becomes something harder to name. The field is not ready for that conversation either.

The question is no longer whether social media shapes the field. It already does. The question is who is shaping social media’s version of mental health—and what it means for the people we serve if the most qualified voices keep deciding that’s not their job.

That’s not a guilt trip. It’s the structural question the field has to answer. And the answer isn’t going to come from a licensing board or a platform algorithm. It’s going to come from individual clinicians deciding, one at a time, what they want to show up for—and what they’re willing to let someone else define in their absence.

A few questions to close with:

• What is your public presence actually for—and is what it’s costing you proportional to that?

• If you have no presence at all, is that a deliberate choice or a slow default you’ve never fully examined?

• When you share mental health content—yours or someone else’s—what are you actually using to evaluate whether it’s trustworthy?

• Who is shaping the public conversation about this work, and does it reflect how you actually understand it?

Fixing this doesn’t require a rebrand or a new website. It doesn’t require much money, either.

Here are four low-lift moves that close that gap—most of which you can do today, most of which are free.

1. Set an Away Message—Even When You’re Not Away

Most clinicians only turn on their email auto-reply when they’re on vacation. But an autoreply doesn’t have to signal absence. It can signal attentiveness.

A message that sets expectations about response times—I typically respond within two business days—does something quietly important: it removes the anxiety of the unknown. New clients especially don’t know what’s normal. They don’t know if you respond within the hour or the week, whether their email landed, whether they should follow up.

A warm, clear auto-response answers those questions before they become a source of worry.

You can also use that space to do light triage work—linking to your website, an FAQ page, or a referral list if you’re not currently taking new clients. The person reaching out gets something useful. You get fewer follow-up emails asking things you’ve already answered somewhere else.

Set it once. Update it when your policies change. That’s it.

2. Put Your Photo on Your Email and EHR Profile

When someone books with you, emails you before their first session, or logs into your client portal for the first time—the experience of seeing a face versus a blank avatar is not subtle.

It’s the difference between arriving at a door that feels occupied and one that doesn’t.

Your profile photo doesn’t need to be a professional headshot, though if you have one, use it. It needs to be clear, reasonably current, and something other than a selfie from two years ago. A clean crop where your face is actually visible does the job.

This takes about ten minutes to update across platforms. It costs nothing unless you decide this is finally the nudge you needed to book new photos—in which case, that’s a separate investment worth making, but not a prerequisite for doing this today.

Subscribe now

3. Create a Template for Getting to You

Whether a client is coming to your office or logging into a telehealth session, the moment before they arrive is often more anxious than the session itself. They’re wondering where to park, what to do when they get there, whether they’re already late. (I know I am feeling this way!)

If you have an in-office practice, write a short paragraph—or a few clear lines—that answers: How do I get there? Where do I park? Do I knock, check in with someone, or wait? Will you come out to greet me, or do I go straight to your office?

If you practice via telehealth, the equivalent is platform orientation. Does your EHR have an associated app clients should download before the first session? Is there a client portal they’ll need to set up? What happens if the connection drops—do they call you, email, wait?

You don’t have to write something elaborate. A short, clear note in your intake paperwork or your confirmation email handles this.

The point is to reduce the I didn’t know what I was walking into feeling that makes a first session harder to settle into than it needs to be.

2. Set Up a Linktree (or Something Like It)

If you’re sending people to your Instagram, your Psychology Today profile, your website, and your booking link through four separate messages or four different spots on your bio—this is the fix.

A link aggregator like Linktree puts everything in one place, behind one link. Free plans are functional. The paid version adds more customization and analytics, but for most clinicians in private practice, the free tier does exactly what you need.

It’s especially useful if you’re active on social media or have multiple offerings: individual therapy, supervision, a newsletter, a consultation call. One link in your bio. One tap to get there.

Free-ish, unless you decide the paid version is worth it. For most of us, it isn’t.

None of these are transformative on their own. But they add up to a practice that feels considered—where someone can tell that you thought about what it would be like to be a client trying to reach you, find you, or show up to see you for the first time.

That kind of care doesn’t require a big overhaul. It mostly requires deciding it matters.

Leave a comment

You can tell a client something deeply personal about yourself and remain, the entire time, psychologically untouchable. That’s not a contradiction. It’s actually the point.

We’ve started using “vulnerability” as a synonym for any moment a clinician reveals something personal—as if disclosure and vulnerability are the same act, just dressed differently. They’re not. And treating them as interchangeable quietly distorts both concepts.

Self-disclosure is a clinical tool. It’s the deliberate, purposeful sharing of something about yourself in service of a therapeutic goal. It can be warm, even intimate, without being vulnerable in any meaningful sense. When you tell a client “I’ve sat with a lot of grief in this room,” that’s disclosure. It may be true, it may land well, it may deepen the alliance. But it doesn’t cost you much. The outcome is reasonably predictable. You’ve handed them something, but you’re still holding the frame.

Vulnerability is different. Vulnerability involves genuine exposure—the kind where you’re not entirely sure how it will land, where something real about you is now in the room and can’t be taken back. There’s risk in it. Not recklessness, but risk. You’re not fully in control of what happens next.

The cleaner way to hold the distinction:

Self-disclosure is an intervention. Vulnerability is a relational condition.

Or even more simply: disclosure answers what am I sharing? Vulnerability asks what am I risking by being known here?

Those are not the same question.

You can be vulnerable without saying a word

Where it gets more complicated—and more interesting—is when you flip the logic entirely.

A clinician can disclose extensively while remaining emotionally armored. And a clinician can be deeply vulnerable without saying almost anything personal at all.

Culturally, we tend to define vulnerability by its content: sharing trauma, admitting struggle, telling a personal story, “opening up.” But psychologically, vulnerability is less about content and more about state—about reduced control over how you’re received, about tolerating uncertainty in real time, about allowing yourself to be affected by what is actually affecting you.

Which means a therapist who says “I went through something similar” may actually be operating from a highly controlled, well-rehearsed place. While a therapist who simply allows themselves to be visibly moved—who pauses because something genuinely landed, whose tenderness is visible, who stops sounding expert for a moment—may be offering something far more vulnerable without disclosing a single autobiographical detail.

Clients often feel this distinction even when they can’t name it. It’s why some highly self-disclosing clinicians can still feel emotionally inaccessible, and why some of the least disclosing clinicians feel profoundly real.

Share

When sharing becomes a strategy

Disclosure can also—and this is the part that rarely gets said—function as a defense.

Not defensively in any malicious sense. Defensively in the psychodynamic sense: it reduces ambiguity, manages the level of intimacy, keeps the emotional field at a controllable temperature. When a clinician always has something to offer—a parallel, a story, a moment of “me too”—it can create the feeling of closeness while quietly protecting against the actual experience of it.

The sharing becomes a kind of management strategy. Something is always available to offer, which means nothing difficult ever has to be felt.

Picture two clinicians. One says “I’ve struggled with that too” in a tone so practiced it asks nothing of the room. The other says almost nothing personal—but visibly softens when a client describes something they recognize in themselves. Clients tend to experience the second as more intimate, even having learned nothing biographical about their therapist. What they’re responding to isn’t information. It’s presence.

This is the paradox. Disclosure, by its nature, can be selected, edited, timed, and clinically metabolized before delivery. It preserves asymmetry. You are still the one choosing what enters the room and when. Genuine vulnerability tends to contain something less controlled—some spontaneity, some irreversibility, some degree of being moved rather than representing having once been moved.

Fluency isn’t courage

There’s a related question worth asking directly: if sharing something requires no resistance to cross, no reluctance to move through, no internal negotiation before it leaves your mouth—is that vulnerability at all?

Therapy culture has developed a particular reverence for clinicians who are willing to “go there.” And willingness matters. But willingness alone isn’t exposure. If a disclosure is easily accessible, smoothly delivered, available on demand—if there’s no bravery involved in the offering—something else is happening.

You may be sharing content that was once vulnerable and has since been so thoroughly processed it no longer carries personal risk. Processed pain, over time, can become narratively polished—recounted with ease, even with a kind of artistry, while the person recounting it remains defended against the actual feeling. That’s not a failure of their therapeutic work. It’s just not vulnerability anymore. It’s memory. And memory, however honest, doesn’t carry the same relational charge as something occurring in real time.

Or you may be sharing something that was never especially exposing to begin with, but that sounds like it should be. Either way, the absence of any felt cost is data.

Vulnerability requires something to be at stake. Not drama, not suffering—but actual skin in the game. The slight catch before you speak. The awareness that this could land wrong, could change how you’re seen, could open something you can’t immediately close. When that’s absent, what you’re witnessing—in yourself or in a colleague—is probably fluency, not courage. And fluency is worth something. It’s just not the same thing.

Not a hierarchy—a distinction

None of which means vulnerability is always the goal.

Contemporary discourse has a tendency to moralize vulnerability—to treat it as inherently good, as the marker of realness, as what separates the authentic clinicians from the defended ones. But not all vulnerability belongs in the room. Not all therapist exposure serves the client. And a well-boundaried, cleanly offered disclosure can be more clinically sound than unprocessed emotional permeability dressed up as presence.

The question was never more vulnerability, less disclosure or vice versa. The question is always: what does this client, in this moment, in this relationship, actually need from me? And that question doesn’t land the same way for every clinician asking it.

Leave a comment

Who gets to take that risk

There’s an assumption embedded in a lot of this conversation: that vulnerability is available to every clinician as a choice. That the decision to be known—or not—is primarily a clinical or personal one.

It isn’t. Not for everyone.

For clinicians who hold marginalized identities, the risk calculus around disclosure and vulnerability is fundamentally different. A clinician of color sharing a personal experience in a predominantly white clinical space, a queer clinician being visible in certain practice contexts, a clinician with a disability or a mental health history deciding how much of themselves to bring into the room—these are not the decisions a clinician with more institutional cover is making. The stakes aren’t the same. The consequences of being known are not distributed equally.

And there’s a subtler layer: whose vulnerability reads as depth, and whose reads as oversharing. Whose emotional presence signals attunement, and whose signals a loss of professionalism. These aren’t neutral judgments. They’re shaped by the same biases and power dynamics that shape everything else.

This doesn’t mean clinicians with marginalized identities can’t be vulnerable—or that strategic protection is the same as emotional unavailability. Selective disclosure in the face of real professional risk is not a defense in the clinical sense. It’s a reasonable response to an unreasonable demand for exposure in spaces that haven’t earned it.

Vulnerability requires safety to be genuine. And safety, in this profession, has never been distributed evenly.

Understanding the difference between disclosure and vulnerability has to include understanding that for some clinicians, the cost of being known is higher—and that reckoning belongs in any honest conversation about what we ask of each other in this work.

Share Practice Forward

How to tell the difference in yourself

A few questions to carry into your work.

• Does this share involve any real risk for me? Not performance risk—but genuine personal exposure. Will something true about me be known in a way I can’t fully control? If the answer is no, you may be disclosing without being particularly vulnerable, which is fine. Just call it what it is.

• Am I sharing to serve the client, or to manage something in myself? Disclosure in service of a client feels different in the body than disclosure in service of your own discomfort. One is an offering. The other is a release valve. They can look identical from the outside.

• Would I share this with any client in a similar clinical moment, or just this one? If the answer is just this one, pay attention to what’s happening between you. Sometimes that specificity is attuned, relational, exactly right. Sometimes it’s a sign you’ve drifted—that something about this particular dynamic is pulling the disclosure out of you rather than you choosing to offer it.

Subscribe now

The same question, on the other side of the room

Everything above applies to you. It also applies to what you’re tracking in the room.

The disclosure-versus-vulnerability distinction isn’t only about what you bring into sessions—it’s one of the more important things to learn to read in your clients. And it’s not always easy, because the surface presentation of both can look nearly identical. A client talking freely, making eye contact, offering detail after detail—that can be disclosure or it can be vulnerability. The behavior alone doesn’t tell you which.

A client can share extensively—their childhood, their relationships, their patterns, their pain—while remaining, underneath all of it, fundamentally protected. The content is real. The history is accurate. But there’s no risk in the telling. It arrives smoothly, without hesitation, without visible cost. They’ve told this story before. They know how it lands. They aren’t waiting to see what you’ll do with it.

That is not the same as vulnerability.

Vulnerability in a client tends to have texture to it. There’s usually some version of not-knowing—uncertainty about whether they should say it, whether you’ll understand, whether it will change something between you. Watch for the small signals: the pause before they say something, the glance away, the trailing sentence, the moment where they seem to arrive somewhere they didn’t plan to go. Affect that surprises even them. The thing they almost didn’t say.

The clinical risk is a specific one: you can leave a session feeling like it went exceptionally well because your client talked more than they ever have, went to places they’ve never gone, seemed open and engaged throughout—and miss entirely that none of it actually cost them anything. The session was full. It felt productive. But real contact may not have been made.

This is worth examining after sessions, especially with clients who present as highly verbal or psychologically fluent. Ask yourself: what was at stake for them in telling me that? If the answer is not much—if the material arrived without friction, without visible uncertainty about how you’d receive it—that’s useful clinical information. It doesn’t mean the session failed. It means you’re learning something about how this client uses sharing, and what might be keeping actual exposure just out of reach.

When you notice the pattern, the intervention usually isn’t more of the same. A client who is disclosing without vulnerability doesn’t need more room to talk—they may need something that gently disrupts the narrative flow. A reflection that names the absence of feeling rather than the content itself. A question that doesn’t follow the logic they’ve established. Slowing down and staying with something small rather than following them to the next detail. Sometimes simply: what’s it like to be telling me this right now?

You’re not trying to manufacture distress. You’re trying to introduce a small amount of relational uncertainty—because uncertainty is precisely what genuine exposure requires. The goal is contact, not catharsis.

Some clients have learned, often through prior therapy, that sharing the right content in the right way produces a particular kind of response. They’re good at this. They may even call it “doing the work.” Part of your job is to gently hold open the question of whether talking about the work and doing the work are the same thing—and to stay curious about the gap between them, without ever making that curiosity feel like an accusation.

Leave a comment

Why it matters beyond the session

This distinction matters long before you ever sit down with a client. It matters in how you build and sustain relationships in your own life.

People who mistake disclosure for vulnerability often find themselves confused by a particular kind of loneliness—one that coexists with what looks, from the outside, like openness. They share readily. They go to the hard places. They have no shortage of things they’re willing to say. And yet something about being truly known keeps not quite happening.

What’s missing is risk. Real intimacy isn’t built on the transfer of information. It’s built on the willingness to be uncertain about how you’ll be received—and to stay present anyway. When disclosure is easy, when there’s no internal friction to cross, it can fill the space where connection might otherwise grow without actually producing it. You can spend years in relationships that feel close on the surface and realize, eventually, that you were never quite in them.

For clinicians especially, this is worth examining. The same patterns that show up in the therapy room show up at the dinner table, in friendships, in partnerships. If you’ve learned to perform openness without actually landing in it—and the profession can absolutely teach you this—that learning doesn’t stay contained to your clinical work.

If you can’t distinguish these things in yourself, you’ll struggle to recognize them in your clients. The client who tells you everything but feels perpetually unseen may not need more space to disclose—they may need help understanding why genuine exposure feels so threatening. The client who insists they’re an open book but never seems to land anywhere tender is showing you something important. You can only name it if you know what you’re looking at.

And when it comes to the therapeutic relationship itself—to rupture, repair, the moments where something real has to pass between you—meaningful relational movement requires that someone take a risk. Not a clinical strategy. Not a well-timed intervention. A risk. The formed instrument knows the difference between offering something and actually showing up for something. Between managing the room and being in it.

The craft is in knowing which is which, and in being honest enough with yourself to call it accurately.

Because underneath all of it—the theory, the clinical questions, the hard-won self-awareness—is something simpler and more unsettling: most of us are more fluent than we are present. More practiced at sharing than we are willing to be found. The work, in the room and out of it, is learning to tell the difference.

If you logged into your CAQH account recently and noticed a new name on the door, you weren’t imagining it. CAQH—the platform most clinicians know as the place they dump their credentialing data every 120 days—is now called DataSpring, powered by CAQH. The rebrand went public on June 8, 2026.

Your login didn’t change. Your data didn’t change. The portal is the same.

What changed is the ownership structure. And that matters more than the name.

This piece is for every therapist on the insurance-based practice spectrum—from the clinician still figuring out what CAQH even is, to the seasoned group practice owner who knows exactly what’s at stake when the infrastructure of your business shifts hands. Start wherever you are.

First: what is CAQH, and why does it run your practice?

If you’ve ever accepted insurance, you’ve interacted with CAQH—even if you only thought of it as that tedious thing you have to re-attest to every four months.

Here’s the actual story.

Before CAQH existed, getting credentialed with an insurance panel meant filling out a separate paper application for every single payer you wanted to join. Every insurer had its own form, its own requirements, its own process. You’d send the same information to ten different places, and then wait—sometimes for months—while each one verified it independently. It was slow, error-prone, and deeply redundant.

CAQH—the Council for Affordable Quality Healthcare—was founded in 1999 by a coalition of health plans specifically to solve this problem. Their solution was the ProView Provider Data Portal: one centralized database where you enter your professional information once, authorize which health plans can access it, and let those payers pull your data directly rather than making you re-submit it every time. Over four million providers now maintain profiles there. The platform is used by more than 1,000 health plans and healthcare organizations across the country.

Think of it as the administrative spine of insurance-based practice.

Your CAQH profile holds your license information, your NPI number, your malpractice insurance details, your training history, your practice locations, your billing information, your education and employment records. It is, in effect, the authoritative source of professional truth that the insurance industry uses to determine whether you are who you say you are and whether you’re qualified to join their network.

Here’s how that plays out in practice:

You decide you want to get on Aetna’s panel. You apply. Aetna goes to your CAQH profile, pulls your data, verifies it against their internal requirements, and—if everything checks out—approves you for network participation. You then appear in their provider directory. Clients who have Aetna coverage can find you listed as in-network. They call you, they come to session, they pay their copay, and Aetna reimburses the rest.

Every step of that chain depends on your CAQH profile being accurate, current, and active.

Now here is where the stakes become very concrete.

Credentialing with a commercial payer takes an average of 90 to 180 days from the time you apply. Most payers do not allow retroactive billing—meaning if you see a client before your effective date clears, those sessions cannot be billed even after your credentials come through. A three-month delay for a therapist seeing 20 clients weekly at a $120 reimbursement rate represents nearly $29,000 in lost revenue that is gone permanently, not delayed. Missing a re-attestation window—something as simple as forgetting to log in and confirm your information every 120 days—can pause your relationship with payers without any clear warning. You often don’t find out until claims start denying.

The stakes are not administrative. They are financial.

The system is, in short, not designed to be forgiving.

Share

So what changed?

Two things happened this year, and the branding announcement has somewhat obscured the more significant one.

The rebrand: On June 8, 2026, CAQH officially became DataSpring, powered by CAQH. Same portal, same login, same data. The CEO described wanting a “fresh, energized” image, particularly around provider relationships. DataSpring holds records for approximately 80% of clinicians nationwide and eligibility information for 75% of covered U.S. lives. They also have plans to launch a “provider data collective” that would establish a national data quality standard. More on that below.

The structural change: On January 6, 2026—five months before the rebrand—CAQH announced it is now owned by twelve shareholder companies affiliated with the nation’s leading health plans. The shareholders are not generic investors. They include UnitedHealth Group, Centene, Aetna, Elevance Health, Cigna, Humana, and several Blues plans.

The CEO said the rebrand is not tied to the nonprofit conversion.

That may be technically accurate. But the two things happened five months apart in the same year, and they cannot be understood separately from each other.

It’s worth sitting with how the ownership announcement itself was framed. CAQH Board Chair Tim Kaja described the change as a continuation of the organization’s founding mission to “solve hard problems and move the industry forward”—language that emphasizes continuity and confidence while offering no real explanation of why the governance change occurred or who the new owners are.

Why the ownership structure is the story

Let’s be precise about what CAQH does, because the conflict of interest only becomes visible when you understand the full picture.

CAQH manages your credentialing data—the information payers use to verify your qualifications and approve you for network participation. Through that data, it influences your directory listings—the way clients find you when they search for in-network providers. It also houses the infrastructure that payers rely on to manage their networks, process provider information, and maintain coordination-of-benefits records for the majority of insured people in the country.

The organizations that now own DataSpring are the same organizations that decide whether to accept or deny your panel application, set your reimbursement rates, determine whether a panel is open or closed, control which providers appear in their directories, and process or deny your claims.

They now also own the database that houses your professional data and the infrastructure through which clients find you.

This is not incidental. This is vertical integration of the administrative spine of your practice.

There is a word for when the same entity controls multiple interconnected parts of a system: consolidation. And DataSpring isn’t the first or only place this is happening.

Share

This is not happening in isolation

DataSpring is one node in a much larger map. And once you see the full map, the DataSpring argument lands differently—because most therapists are already several layers into insurer-adjacent infrastructure without fully realizing it.

Start with the platforms.

If you use Headway, Alma, Grow Therapy, Rula, or SonderMind to handle your credentialing, billing, or client acquisition, you are interacting with companies that are themselves funded by the same major insurers now sitting on DataSpring’s board. Headway’s lead investor is Health Care Service Corporation—the country’s largest customer-owned health insurer and an independent licensee of Blue Cross Blue Shield—with additional investment from Evernorth Health Services (Cigna), BCBS of Massachusetts, and BCBS of Texas. Alma and Grow Therapy are heavily backed by Cigna Ventures and Optum Ventures, the investment arm of UnitedHealthcare.

The companies that determine your reimbursement rates hold equity stakes in the intermediaries through which you access those rates.

This means the same insurers that now own DataSpring’s credentialing infrastructure also co-own the practice management platforms that sit between you and your clients.

For many therapists, these platforms are a practical bridge—particularly for clinicians who find the administrative burden of independent credentialing prohibitive, or whose reimbursement rates make solo insurance participation financially unsustainable. That’s a real problem with a real structural cause. But it’s worth understanding what you’re entering when you join: a system where your credentialing data lives in a database owned by insurers, your billing runs through a platform funded by insurers, and your client referrals flow through a directory shaped by those same entities. The administrative friction that makes platforms feel necessary is not separate from the consolidation problem. It’s part of how consolidation expands.

There are also meaningful risks in platform dependency beyond the philosophical. Therapists who have exited these platforms report losing access to billing records and patient data mid-transition, with accounts shut down earlier than contracted and no straightforward recourse.

Now add the practice acquisition layer.

Mental health was the most active sub-sector of all behavioral health mergers and acquisitions in 2025, with 111 documented transactions. Private equity-backed behavioral health companies are acquiring outpatient mental health practices at an accelerating rate—and some acquirers have deliberately kept individual deals below the Federal Trade Commission’s antitrust review threshold of approximately $119.5 million, specifically to avoid scrutiny. The aggregate effect is significant consolidation; the individual transactions fly under the radar.

This pattern is not unique to mental health. Across medicine, by 2024, approximately 78% of physicians were employed by or affiliated with hospitals, health systems, insurers, private equity-backed entities, or other corporate employers. Independent practice has become the minority position in most specialties.

But the clearest proof that this concentration creates real risk for providers and clients alike isn’t a trend line or a market report. It’s a specific event that happened in February 2024.

We already know what centralized failure looks like

On February 21, 2024, a ransomware attack hit Change Healthcare—a clearinghouse that routes insurance eligibility verification, prior authorizations, claims, and payments between providers, payers, and pharmacies. Change Healthcare had been acquired by Optum, a subsidiary of UnitedHealth Group, in October 2022. It processed approximately one-third of all healthcare claims in the United States—about 15 billion transactions annually.

When it went down, it took much of the healthcare billing system with it.

Seventy-four percent of hospitals reported direct patient care impact, including delays in authorizations for medically necessary care. Ninety-four percent reported financial impact. Mental health and substance use providers—who were already operating on thin margins with high administrative complexity—were left unable to obtain insurance approval or receive payment for services while their clients remained in urgent need of care. The total cost of the attack exceeded $2.4 billion. Nearly 193 million individuals had their protected health information exposed.

When a single entity processes a third of all national claims and goes offline, the consequences are not contained. They are systemic.

The Change Healthcare incident is the proof-of-concept for why concentration risk in healthcare infrastructure is not theoretical. Patients can’t access care. Providers can’t get paid. Change Healthcare was exactly what DataSpring is now becoming: a centralized, mission-critical infrastructure node, concentrated under the ownership of a major insurer, where a single point of failure can cascade across the entire system.

Leave a comment

The critical analysis: what needs to be said directly

Healthcare consolidation is not a background trend. It is an accelerating structural transformation of the entire industry—and it is not accidental, and it is not neutral.

For independent therapists and small group practices, the concern is not dramatic or immediate. No one is going to wake up tomorrow to find their CAQH profile weaponized against them. The concern is structural and slow-moving. It’s about whose interests the infrastructure is ultimately designed to serve—and whether those interests align with yours.

There is a legitimate question about what happens when the entities that own the credentialing infrastructure also set the rules for network participation. If DataSpring develops tools or data products that help payers optimize their networks—deciding which providers to include, which to deprioritize, which specialties are over- or under-supplied—the owners of that intelligence are the same companies making those decisions. That’s not a conspiracy. That’s how business works. But it is worth naming.

There is also a legitimate question about what happens to provider data that extends beyond credentialing use. Aggregated, de-identified data from 4.8 million provider records and 75% of covered U.S. lives is extraordinarily valuable—for market analysis, competitive intelligence, network modeling, actuarial work. In a nonprofit structure, there are constraints on how that value is extracted and for whose benefit. In a for-profit structure owned by the industry’s largest payers, those constraints are different.

None of this means the worst will happen. The CEO has stated a commitment to improving the provider experience, and faster credentialing, cleaner data, and less duplication are genuine potential benefits. But regardless of what any individual leader intends, ownership changes incentives. A board accountable to twelve shareholder companies with a direct financial stake in network management, reimbursement, and claims will, over time, make decisions shaped by that accountability—not because anyone involved is acting in bad faith, but because that’s what accountability structures do.

A well-intentioned leadership team is not the same as a governance structure that protects provider interests over time. That’s why structure matters.

The equity layer

Any analysis of this kind that doesn’t name the equity dimension is incomplete.

Who bears the administrative burden of credentialing most heavily? Independent clinicians—especially those building practices without administrative infrastructure, credentialing coordinators, or billing staff to catch the errors that trigger delays. For a solo therapist navigating five payer applications simultaneously, an 85-day credentialing delay is a cash flow crisis. For a large corporate behavioral health platform with dedicated credentialing teams, it’s a workflow inconvenience.

When infrastructure consolidates and becomes less transparent, the providers most vulnerable to being disadvantaged are those operating without institutional backing. This disproportionately includes providers from communities that have historically been underrepresented in private practice and underserved by corporate behavioral health networks—the very clinicians whose presence in the system matters most for access and cultural match.

The access side of this is equally important. Health insurance disparities already disproportionately affect BIPOC communities, limiting which providers people can afford to see. Only about 33% of Black adults with mental illness receive care, compared to 48% of white adults. The shortage of culturally matched, insurance-accessible therapists is not a minor gap—it is a documented crisis.

When clients can’t find culturally matched providers in-network because those providers face disproportionate administrative barriers, the consequences are not administrative. They are clinical.

When the infrastructure that controls credentialing, directory visibility, and network participation is owned by the same entities that set reimbursement rates and network access rules, independent therapists serving underrepresented communities have fewer structural protections—and the friction this creates doesn’t stop with providers.

Why clients should care, too

Everything in this piece so far has been framed around therapists—your revenue, your practice, your professional infrastructure. But the chain doesn’t end there, and it’s worth tracing all the way through, because clients tend to appear in these conversations only as a downstream afterthought.

Here’s the chain, stated plainly.

If credentialing becomes slower, more expensive, or more administratively burdensome—whether through fees, delays, or simply more friction in an already difficult process—fewer therapists will have the bandwidth or the incentive to join insurance panels. Some will choose to go fully out-of-network. Some will stay on platforms that handle credentialing for them but extract a percentage of every session in return. Some will simply not pursue certain panels at all, especially the ones with the worst reimbursement rates relative to the administrative cost of getting on them.

If fewer therapists are in-network, network adequacy gets worse. Network adequacy is the technical term for whether an insurance plan actually has enough providers, in the right specialties, in the right locations, to meet the needs of the people it covers. It’s already a known problem in behavioral health—client-facing directories are notoriously inaccurate, and “ghost networks” of providers who are listed but not actually accepting new patients, or no longer in-network at all, are a documented issue across the industry.

If network adequacy worsens, clients feel it directly. They wait longer for an appointment. They travel farther to find an in-network provider who’s actually taking clients. They’re more likely to give up and go without care, or to end up paying out-of-pocket for a provider they could have seen in-network if the system worked the way it’s supposed to. For clients seeking a culturally matched therapist—already a narrow search in many areas—any additional friction in the system disproportionately narrows their options further.

This is the part of the story that rarely gets told, because it requires connecting administrative infrastructure to lived experience across several steps. But the steps are real, and they’re not hypothetical. They’re the difference between a system that makes it easier for the right client to find the right therapist, and a system that adds friction at every layer until fewer of those connections happen at all.

Share

The long-term implications

Over a longer arc, there are several things worth watching:

Will DataSpring introduce fees for providers? As a nonprofit, the provider-side portal has been free. That constraint changes with the ownership structure. Nothing has been announced, but it is a reasonable question to track.

How will the “provider data collective” work? DataSpring has announced plans to bring together industry stakeholders to set a national data quality standard. Who participates in that process, and how much influence independent clinicians and small practices have relative to large health systems and payer-affiliated entities, will shape whether it serves providers broadly or primarily those with scale.

What happens to disputed profiles? The nonprofit structure came with at least some nominal orientation toward serving the industry as a whole. In a for-profit structure with payer shareholders, the mechanisms for resolving disputes about provider data—and whether providers have recourse—are worth understanding.

What happens to independent practice visibility? Directory accuracy and directory prominence are not the same thing. As data products evolve, it’s worth watching whether directory tools prioritize clinical fit and geographic access or optimize for network cost management.

What are the concentration risk and cybersecurity implications? Change Healthcare demonstrated that centralized healthcare infrastructure is also a concentrated attack surface. DataSpring now holds credentialing data for 80% of clinicians and eligibility records for 75% of covered lives. That is a significant data asset—and a significant vulnerability.

What to do right now

The practical answer is short. There is no immediate action required beyond what you were already doing.

Keep your profile current. Same portal, same URL (proview.caqh.org), same login. The name has changed; nothing about your access has.

Know your attestation window. Every 120 days. Set a calendar reminder. Missing it can interrupt payer relationships without warning.

Audit your directory listings. Pull up your profile in the major payer directories you participate in—your Aetna directory listing, your BCBS listing, wherever you’re paneled. Confirm your name, specialty, location, and contact information are accurate. Errors there affect whether clients can find you.

Understand your platform dependencies. If you use Headway, Alma, Grow, Rula, or similar services, know what data they hold on your behalf, what your contract says about data access if you leave, and who their investors are. You don’t have to exit these platforms—many therapists have good reasons to use them—but you should make that decision with full information.

Read communications from DataSpring. If changes to fees, terms of service, or data use policies are coming, they’ll announce it. Read the email instead of archiving it.

Stay in the professional conversation. Licensing boards, professional associations, and advocacy organizations will be watching this. You don’t have to do anything today, but being an informed clinician means knowing when something structural shifts—and this qualifies.

Share

The larger question

The conversation about DataSpring is ultimately a conversation about who owns the infrastructure of care and whose interests it serves.

That question doesn’t have a clean answer, and there are reasonable people who will look at this transition and see efficiency gains and innovation potential before they see conflict of interest. That’s a legitimate read. But it’s not the only one.

We are building our practices inside a system that is becoming more consolidated, more interconnected, and increasingly controlled by fewer and fewer entities. The same organizations that set reimbursement rates are acquiring the technology platforms that host our data, the benefit management companies that process our claims, the practice management intermediaries through which many of us access insurance panels, and now the credentialing infrastructure that determines whether we can participate in networks at all.

That’s not alarmism. That’s the direction of the industry, documented in federal reports, government audits, antitrust proceedings, and—as of February 2024—a ransomware attack whose blast radius reached every corner of the healthcare system.

We understand that the structure of a system shapes the outcomes it produces. We understand that “functioning as intended” looks different depending on whose intentions you’re asking about.

Therapists spend their careers thinking about relationships, trust, and power. We understand that systems shape outcomes just as surely as people do—that the structure of a relationship, a household, an institution, often determines what’s possible inside it long before any individual’s intentions come into play.

The question raised by DataSpring is ultimately not whether credentialing will become more efficient. Efficiency is achievable under almost any ownership structure, and it may well improve. The real question is whether the infrastructure of care—the systems that determine who gets to provide it, how, and to whom—will remain accountable to the people who provide it and the people who depend on it.

Nothing catastrophic changes overnight. But paying attention to who holds that accountability, and to whom, is not a distraction from the work. It’s an extension of it.

I love the story of how my parents met. Really, I love the story my dad tells about how they met.

As he tells it: my mom was working the cash register at her family’s restaurant, the Hong Kong Kitchen, and my dad would take his lunch breaks there. That’s the whole setup. Boy walks into restaurant, girl is at the register, the rest is my existence.

This essay is not a retelling of that love story, or how yours truly came to be, except to say this: my parents came from blue collar immigrant families.

Before the restaurant, my mom’s family owned a laundromat. She doesn’t talk much about that time, other than to describe how hot it got inside when she was a little girl, and the chemicals they were always around. That’s all she offers. I’ve never pushed for more.

Nobody was calling them entrepreneurs.

That word “entrepreneur” has always traveled selectively.

It lands on certain people, in certain industries, with certain aesthetics—and it tends to skip right over the woman at the cash register, the family hauling laundry in the back, the people doing the same fundamental thing but without the pitch deck or the personal brand. My mom’s family wasn’t building a legacy. They were making a living. The distinction, I’d argue, is mostly optics.

There were no Instagram reels. No income transparency breakdowns. No one was buying a course on how to evolve your laundromat to a cash-pay-only model.

They were just people who owned a thing, worked it themselves, and adapted continuously—because that was what was available to them, and because survival has always required a certain kind of improvisation that only gets called resourcefulness (or “grit”…gross) in retrospect. Or, if you have the right background and the right platform, gets called entrepreneurship.

The therapists debating whether it’s ethical to sell a course, become a content creator, whether monetizing your expertise is a compromise of the work, whether we should be building personal brands at all—that debate is real.

AND, IMHO it also requires a certain amount of distance from survival to have it. My mom’s family didn’t deliberate about whether owning a restaurant was philosophically consistent with their values. They needed the restaurant.

The privilege isn’t just in who gets called an entrepreneur. It’s in who gets to have opinions about whether entrepreneurship is something to aspire to in the first place.

I think about my parents a lot when I watch the discourse unfold in our profession around income diversification—because there is a lot of judgment in it, and judgment, I’ve learned, is often just distance wearing a moral costume.

Share

Two Conversations Pretending to be One

The discourse around income diversification for therapists is loud, layered, and moves fast.

It usually starts with the visible stuff: the income transparency videos, the tips on pivoting to cash pay, the courses you can buy on building something beyond the 50-minute hour. That’s one conversation.

But it expands quickly into a more global one—different, but related. About whether therapists should have to side hustle at all. About what it means that someone can accumulate a graduate degree, significant student loan debt, and a series of unpaid or barely paid internships, and still arrive at licensure into a system where the reimbursement math is nearly impossible to make work. About the unfair, unjust nature of this work and the unfair, unjust systems we work inside.

Both conversations are legitimate. And they’re getting tangled in ways that deserve to be pulled apart.

Because at the end of the day, you’ve got one corner judging therapists for monetizing their expertise, another arguing it’s not only okay but necessary given how much we’ve already given away for free, and yet another saying we shouldn’t be in this position at all—that hustle culture is the problem, the economy is rigged, and adapting to a broken system is just helping it limp along.

So what’s a therapist supposed to do with that? How are they supposed to feel?

(Spoiler: I am not, and have never been, here to tell you how to feel about something.)

Share Practice Forward

Be Vulnerable Enough and They’ll Call it Brave

I’ve been inside this conversation for a long time—not just as an observer of the discourse, but as someone who has had to navigate it personally, practically, and with real stakes.

When I started my practice, I wasn’t romanticizing any of it. If anything, I was clear-eyed to the point of fear—afraid it would fail, afraid it would be a waste of time and money I didn’t have. Which is why I kept my full-time faculty position and built the practice on the side, in the margins, until it wasn’t a side thing anymore. Even then, knowing when to make the transition took longer than I expected, more conversations than I expected, and eventually just required a leap.

What that careful, methodical approach didn’t prepare me for was the visibility part. And I want to be honest: what visibility even means has shifted considerably since I first opened my doors.

What’s Visibility to YOU?

In the beginning, visibility was relatively contained. A Psychology Today profile. A website. Maybe a handful of referral relationships. The goal was being found, not presence.

That’s not the landscape anymore—and how much that matters depends almost entirely on where you want to take your work. If you’re building toward speaking engagements, brand partnerships, a community, a course, a book—the expectation is a different kind of showing up. Across platforms, consistently, with intention. The absence of a strategy is its own strategy, and usually not a good one. (Even though, most therapists will say they stumbled into visiblity and then became consistent and strategic.)

But even for clinicians who aren’t chasing any of that—who just want a full caseload and a sustainable practice—the algorithm has started demanding more anyway. More content. More of you. More evidence that there is a person behind the credentials who is relatable and real and worth following.

Subscribe now

Feed the Machine

Here’s something nobody really prepares you for: no amount of caution, no amount of careful, methodical practice-building, fully prepares you for what the algorithm eventually wants from you.

And what it wants, I’ve come to believe, is the last thing we have left to offer that hasn’t already been optimized and commodified. Not your credentials. Not your modalities or your fee range or your years of experience.

What the market has identified as the remaining resource—the final frontier, so to speak—is YOU. Your stories. Your vulnerability. The unguarded, unpolished, still-figuring-it-out version of yourself that we spent years of clinical training learning to carefully contain.

Here’s the incongruence: we are trained to be extraordinarily cautious about self-disclosure. Abstinent, even. The clinical literature on therapeutic boundaries does not exactly encourage you to build a content strategy around your inner life. And then we graduate, open practices, and discover that the economic reality of getting clients in a saturated market requires exactly the kind of visibility our training told us to be careful about. That’s not a small contradiction to hold. For a lot of clinicians, this is precisely where the wheels come off—not because they don’t want to market themselves, but because every instinct their training developed is pulling in the opposite direction.

Share

And capitalism, being capitalism, found a way to exploit that gap.

The insidious part is that it doesn’t feel coercive. It feels like connection. It feels like community. It feels, genuinely, like helping people—because sometimes it is. The algorithm rewards you emotionally and economically at the same time, which makes it nearly impossible to locate where the authentic impulse ends and the market incentive begins.

(Note: I’m still working through my own feelings about what it means to share my ideas, feelings, and opinions publicly. It’s not quite my life story or full access to my history, but it is a glimpse—and even that feels strange most days.)

Share

You Have Approximately Three Seconds

And the platform doesn’t just reward the self—it shapes which version of the self gets rewarded.

Nuance doesn’t stop the scroll. Complexity doesn’t go viral. What performs is the sharp take, the relatable confession, the before-and-after. The algorithm doesn’t have a setting for “thoughtfully ambivalent” or “still working through this carefully.” It has a setting for attention, and attention requires sensation. You have seconds—genuinely, seconds—to stop a scroll, create a feeling, make someone decide you’re worth their time.

The therapist who is most comfortable being vulnerable online is not necessarily the one doing it most thoughtfully. And the one doing it most thoughtfully is not necessarily the one being rewarded for it.

You can put something true into the world and watch it get consumed in a way that has nothing to do with why you said it. You lose authorship of your own disclosure the moment it leaves you.

For many clinicians, particularly those who came to this work through their own attachment healing, visibility isn’t just uncomfortable. It can feel dangerous. Opening themselves up to micro and macroaggressions, online bullying, sexualization, etc.

There’s a difference between experiencing something and performing it for an audience, and for people who have spent years learning to trust that distinction, being asked to collapse it in service of building a practice can feel like a real cost.

Even I’ve grown more comfortable sharing publicly over time. And I still have internal lines I’m aware of constantly—places where something in me goes quiet, where I feel the pull toward sharing and simultaneously a protective resistance I’ve learned to respect rather than override.

That's discernment. We should be allowed to name it that way without it being read as an unwillingness to be real.

Subscribe now

The Algorithm Rewards Mess

Whether we like it or not, the people most rewarded in this space tend to be comfortable being a work in progress publicly. Not the ones who have it figured out, but the ones visibly figuring it out—sharing the learning as it happens, the missteps alongside the wins, the process rather than the polished outcome. The clinicians holding back until they feel ready, until success looks the way they imagined it—they’re often waiting a long time.

(Fortune favors the bold…audacity is rewarded over perfection…you know all the sayings, yadda yadda…)

I have complicated feelings about that. Being a public “work in-progress” requires time, bandwidth, and psychological safety that isn’t equally available to everyone. I have more of those things than my family did. That’s not a small difference—it shapes what risk is absorbable, how long you can stay in the messy middle before it needs to pay off.

Knowing that doesn’t diminish what I’ve built. But it makes me slower to judge the people who aren’t building it, or aren’t building it the way the current moment rewards.

Share

Let's Name What We're Actually Reacting To

Part of why these conversations carry so much charge right now is that we’re coming down from two cultural hangovers simultaneously—and most of us haven’t fully named them.

The first is hustle culture, which spent a decade rebranding overwork as identity. The second is the girl boss “lean in” era (where are my Millenials at?!), which arrived as a feminist corrective and turned out to have its own serious problems—largely white, largely middle class, individualist in ways that obscured structural barriers rather than dismantling them. It dressed up capitalism in empowerment language and called it progress. And then we watched both frameworks collapse in real time.

And (for good measure) an older one: the disillusionment of realizing the meritocracy our parents handed us was never quite as advertised.

Some of the suspicion directed at therapist-entrepreneurs now—the MLM comparisons, the side-eye at income transparency content—is carrying residue from those disappointments. Which is understandable. But it helps to know what you’re actually reacting to, so you’re aiming at the right target.

Subscribe now

The Target is Not Your Colleagues

We are a profession built around the value of human wellbeing, operating inside an economic system that has never meaningfully organized itself around that value.

We were trained to believe that helping people is the payoff. And it is. But it is also, apparently, not enough to pay rent.

The very conditions we operate under produce the gatekeeping we all claim to oppose.

When clinicians get creative about survival—diversifying, building an audience, charging what their time commands outside of insurance—and corners of our own profession look sideways at them, that’s scarcity doing its work. It turns colleagues into competitors. It makes people guard information rather than share it.

The critique belongs to those conditions, not the clinicians adapting to them. You can hold a full critique of the structure that put us here and still cheer for the therapist who built the group practice, figured out a speaking income, launched the thing. Those are not in conflict.

That said, and I want to hold both of these honestly, there’s something that deserves examination in how the economy around sharing has evolved. The observation that this space sometimes feels like an MLM isn’t coming from nowhere.

The shape rhymes even if the mechanics differ: someone builds a platform, newer clinicians follow, some build their own platforms, courses get recommended, referral loops form. Nobody necessarily doing anything wrong. And yet when visibility becomes the primary product—when content about building a practice becomes more scalable than the practice itself—we’ve arrived somewhere that warrants a pause. Not as accusation. As honest observation.

Leave a comment

Turns Out Grad School Had Something Useful To Say

Here’s where our training is useful, if we let it be.

Clinical self-disclosure is not the absence of limits dressed up as authenticity. It is a decision—intentional, bounded, in service of something beyond our own relief. The question we were trained to ask before sharing anything in the room isn’t would this feel relatable? It’s whose needs does this serve?

Disclosure that relieves the clinician, that performs humility rather than offering it, that makes us the empathic protagonist of someone else’s story—that’s a clinical error. We know this. We take it seriously inside the room. And then many of us step into a public professional presence and leave that orientation entirely behind.

What if we didn’t? Not as a restriction—as a compass. The question isn’t whether to be visible. Visibility can be genuine generosity—sharing what you know, naming what the system costs, refusing to pretend this is easier than it is. The question is whether what you’re sharing is in integrity with why you’re sharing it. Whether the version of yourself the algorithm rewards is one you’d recognize the next morning.

Share

Back To The Cash Register

• Can we not feel joy about what we’ve built?

• Can we not take up space with our pride in it—expansively, without apology—and have our colleagues cheer us on like we mean it?

• Can we not say this is what I believe my time is worth without someone reading it as greed or naivety or a betrayal of the work?

• Can we not want to make money—good money, real money—without that want becoming its own indictment?

• And can we stop perpetuating the very narratives of scarcity and competition that are already harming us—that the system has always relied on us to perpetuate—every time we look sideways at a colleague who’s figuring it out?

At the same time, and I want to hold this carefully: for some of us, the hustle was never a choice. It was a condition. And there is nothing romantic about that. Romanticizing it bypasses the very real harm the system has done to people who didn’t get to deliberate about whether building something aligned with their values. They just needed it to work.

You can share freely and charge for your time. You can be transparent about money without making transparency itself the product. You can take pride in building something—in the resourcefulness of it, the freedom it promises, even knowing that promise isn’t evenly distributed—without pretending the system is fair. You can critique what made the side hustle necessary and still feel good about what you’ve built within it.

That’s ownership. Not in the business plan sense—in the older, quieter sense my family understood it. You decide what the thing is. What it costs. What it means and who it’s for and how much of yourself goes into it and how much you hold back. Nobody hands you that. You build it, usually slowly, usually imperfectly, usually while managing the voice that says you’re doing it wrong.

In the moments when I doubt that, I think about my parents. Not to romanticize what they survived, but to borrow something from it. That’s not hustle culture.

That’s just the quiet inheritance of people who kept going.

Subscribe now

(Uncomfy) Questions to Ask Yourself

• Whose choices are you quietly side-eyeing—and do you actually know their story? Not the version you’ve constructed from their content, but what brought them to this work, what they’re carrying, what the math looks like from where they’re standing. Judgment moves fast. Context takes longer.

• Where did you learn what it means to charge what your labor deserves? What did the people who raised you model about money, about asking for things, about what work earns—and how much of that is still running quietly in the background of every pricing decision you make?

• Is your resistance to visibility about sharing itself, or about not yet being clear on what the sharing is for? There’s a meaningful difference between not being ready and not knowing the purpose. One is timing. The other is direction.

• And finally: what version of success are you holding out for—and is it actually yours, or did you inherit it from somewhere you haven’t fully examined yet? From a training program, a supervisor, a family that never had the luxury of asking that question at all?

  Thanks for reading Practice Forward! Subscribe for free to receive new posts and support my work.

What I don’t want to watch is supervisees navigating that space without a compass. The doubt that accumulates quietly—in the session that felt flat, in the cancellation that stings, in the moment a client mentions they’ve found a lot of value in a podcast lately—is real. It shows up in retention. It shapes how you present yourself professionally. It can start to feel less like practicing and more like selling the idea of yourself as a clinician.

I’ve watched this across years of supervision, and before that, across years of teaching practicum and internship in a clinical mental health counseling program. We would review session recordings as a group—footage of real clinical moments—and I would ask students to account for their choices with a level of precision that made the room get quiet.

Not: What technique did you use?

But: Why did you ask the client how they were feeling right at that moment, and not a moment before or after?

• What made you bring them into their emotional experience rather than their cognitive one?

• When you shifted the conversation in that direction, what theory told you that was the right move?

• When you asked a question that took the client into their head instead of their body—was that intentional? And if it was, what were you building toward?

The students weren’t careless. They were thoughtful, committed, genuinely trying. What they often couldn’t do was explain the why underneath the what—the clinical logic connecting the micro-decision in the room to an understanding of this person, this pattern, this theory of change.

This is what I kept returning to in those review sessions: there is a difference between moving a session and moving it somewhere.

Between building rapport and building rapport toward something. Validating a client, comforting them, reflecting their feelings—none of that is wrong. But none of it is clinically neutral either. Timing matters. Direction matters. Whether you bring a client into their body or their intellect in a given moment is a theoretical choice, whether you’re conscious of it or not. When you’re not conscious of it, you’re still making it. You just don’t know what you’re doing or why.

That’s what we’re going to focus on. The specific aspect of professional identity that holds or breaks the rest of it is theoretical orientation.

Let’s Define the Thing First

Theoretical orientation is your clinical worldview. The set of assumptions you hold—some explicitly, some not—about the nature of the self, the role of relationships, the function of symptoms, and the mechanisms of change.

Every major orientation answers the same underlying questions: What causes distress? What sustains it? What does the therapeutic relationship do? What is the clinician’s role? A psychodynamic lens locates meaning in the unconscious and in relational patterns formed early in life. A cognitive-behavioral framework centers the relationship between thought, emotion, and behavior. A humanistic orientation emphasizes the inherent drive toward growth and the conditions that support or obstruct it. An attachment-based lens follows how early bonds shape the capacity for safety and connection.

These distinctions are not academic. They shape everything—how you listen, what you track, where you intervene, and what you understand the goal of treatment to actually be.

As a Star Wars fan, I’ve come to think about theoretical orientation the way I think about the Force. Not as a mystical ability that some clinicians are born with—but as the underlying energy that makes all technique meaningful. A Jedi doesn’t become effective by collecting lightsaber moves. They become effective by developing their relationship to the Force itself: the philosophy, the attunement, the understanding of what it is and how it works. Strip the Force and lightsaber skills are just choreography.

The same logic applies here. A thought record, a somatic intervention, an empty chair exercise—these are techniques. What makes them work, when they work, is not the technique itself but the clinical understanding driving its use: why this, for this person, at this moment, toward what end. Strip the theory and you have well-trained, potentially evidence-based choreography. You can execute perfectly and still not be in the room.

Share

Two Questions Worth Actually Sitting With

When I was working out my own theoretical grounding, the questions that helped most weren’t from a textbook. They were philosophical. And they cut straight to what I already believed before I had language to name it.

These sound simple. They’re not. Your answers will tell you more about your theoretical home than any orientation overview could—because they surface what you believe before a framework confirms it.

How change occurs is a question about the engine of transformation. If you believe change comes through insight—a client finally understanding the relational pattern they’ve been living inside—that points toward psychodynamic or relational work. If you believe the therapeutic relationship itself is the mechanism—that being seen and responded to differently is what reorganizes the self—you’re in attachment territory. If you believe change lives in the body, somatic and trauma-informed approaches will make the most sense. If you believe it comes through shifting the relationship between thought and behavior, cognitive-behavioral frameworks will feel coherent.

These are not stylistic differences. They are different theories of what a human being is, what distress means, and what the work is actually for. Working from a framework that doesn’t match what you genuinely believe creates friction you’ll feel in every session, even when you can’t name it.

How anxiety forms is a question about the nature of distress—where it lives, what it signals, what it’s doing. A conditioned response that has generalized past its usefulness? A signal from the unconscious that something unresolved is pressing toward the surface? A physiological state the body got stuck in? The inevitable companion to freedom and the awareness of our own limits? Each maps onto a different framework and points toward a different intervention logic. If anxiety is a conditioned response, you expose and relearn. If it’s a signal, you listen and interpret. If it’s physiological, you regulate and complete. If it’s existential, you sit with it and find meaning.

Subscribe now

Five Questions Worth Answering Honestly

The two above give you a starting point. These five will take you deeper. Don’t answer them the way you think you should. Answer them the way you actually do.

1. When clients improve, what do you believe is actually happening?

2. When clients stay stuck, what do you think is maintaining that?

3. What role does the therapeutic relationship play in change—is it the vehicle, the mechanism, or the context?

4. What do symptoms mean to you?

5. What do you find yourself paying attention to most in session—thoughts, the body, relational patterns, narrative, something else?

Your responses won’t tell you which theory is right. They’ll tell you which theories already feel true. A clinician who finds themselves always tracking the relational dynamic in the room—even when the presenting concern is cognitive—is probably not a CBT clinician at heart, regardless of what training they completed. A clinician consistently more curious about what a symptom is protecting than about how to reduce it is working from a different theory than someone who leads with symptom elimination.

Orientation is not a personality type. But you have to start somewhere honest—with what you actually believe, not what you’ve been trained to deliver.

Share

Signs You Need More Theoretical Grounding

If you’re unsure whether this work is pressing for you, these are honest markers.

You dread being asked why you chose a particular intervention—and your answer tends to be that it worked for someone else, or that it seemed relevant, or that it was in the protocol.

When a session goes sideways, you know it felt off but you don’t have a framework for understanding why.

You change approaches with the same client frequently, following their lead on what to try next, with no through-line connecting the decisions.

Your case conceptualizations describe what’s happening without a theory of why—or why now, or what’s maintaining it.

You feel noticeably more grounded with a structured protocol than without one, and when a client deviates from the structure, you’re not sure what to do.

You find yourself validating whatever framework a client arrives with—partly because it feels collaborative and partly because you don’t have a competing clinical lens to offer.

In supervision, you present cases and receive direction. You rarely discuss how you understood the case and why.

None of these are indictments. They’re recognitions. And they point to the same place.

Share

The Training

Identifying your orientation through reflection is the beginning. Building it is ongoing, and it has a few reliable components.

Read primary sources, not summaries. Summaries strip the philosophy. I remember reading Bowlby for the first time—not a textbook account, the actual theory—and having a quiet recognition I didn’t yet have language for: this is how I already understand people. That moment didn’t resolve everything. But it told me where to look. Primary texts give you the theoretical architecture—the why underneath the what. That architecture is what you’re actually building.

Get into supervision that engages with conceptualization, not just case management. There’s a version of supervision where you present a client, receive direction on next steps, and move on. That version manages your caseload. The supervision that develops you asks: how are you understanding what’s happening with this client? What’s your theory of what’s maintaining this? Why that intervention and not another—and why at that moment? Those questions, asked consistently over time, force you to articulate your own clinical logic rather than just execute it.

Do your own therapy. Not because you’re required to—because you will understand change differently from inside it than from observing it. You’ll feel your own resistance. You’ll feel what change costs. You’ll develop a respect for what your clients are being asked to do that no training can replicate.

Practice explaining your rationale out loud—in supervision, in peer consultation, even to yourself after sessions. Say: here’s what I believe is happening with this client, here’s what I think is maintaining it, and here’s why I chose that intervention at that moment and not another. The first several times will feel uncertain. That uncertainty is the work.

Notice what draws you. When you read about a framework and feel something light up—curiosity, recognition, the sense of yes, that’s how it works—follow it. That’s not intellectual whim. That’s your clinical instincts pointing toward their home.

Share

The Chain That Holds It Together

Theoretical orientation is the first link in a chain.

Your orientation gives you a framework for case conceptualization—a way of organizing and making meaning of a client’s history, patterns, and presenting concerns that goes beyond the symptom checklist. Case conceptualization gives you a map of the client’s problem set: not just what is happening, but why it might be happening and what might be maintaining it. From that map, you can make informed decisions about which techniques are most likely to support the change your client is working toward—and why you’re making them when you are.

Without the first link, the chain doesn’t hold. You can still pull techniques—there are entire databases of them—but you’re applying them to a picture you don’t fully understand. Treating symptoms rather than systems. And clients feel that, even when they can’t name it.

This is not a critique of structured interventions or evidence-based practice. But structure without conceptualization is a protocol without a practitioner—and your client hired one.

Leave a comment

Why Grad Programs Weren’t Wrong About This One

Graduate programs can be genuinely annoying about theoretical orientation. The pressure to pick one, defend it, stake a claim—it can feel reductive, like being asked to choose a team before you’ve seen anyone play.

Early in my own practice, I gravitated toward frameworks that gave me something concrete to offer. Structure felt like safety. I could follow a protocol and know I was doing something. What I didn’t yet understand was that I was confusing activity with direction—I was busy in sessions without always knowing what I was building toward or why.

What shifted wasn’t a single training or a defining supervision session. It was accumulative: clients who didn’t respond the way the protocol suggested they should, supervisors who pressed on my clinical reasoning rather than just affirming my choices, my own therapy surfacing how much I’d been intellectualizing away from what I actually felt. I started noticing a gap between what I was formally doing and what I was actually curious about in the room—the body, the relational undercurrent, the thing a client said two sessions ago that was quietly connecting to something happening now. That gap was trying to tell me something about where my orientation actually lived.

What I got wrong early on was treating orientation like a methodology you choose and then execute. What I’ve come to understand—and what I try to hold for supervisees navigating this same territory—is that orientation reveals itself as you work. The clients who confound you, the cases that don’t resolve cleanly, the moments when a protocol runs out and you’re left holding a room full of something unnamed: those are often where your actual clinical beliefs surface. That’s not failure. That’s formation.

The insistence of graduate programs to commit to something isn’t arbitrary. It’s trying to build something genuinely hard to teach: the capacity to hold a coherent theory of change and apply it under pressure, in real time, with a real person who is not cooperating with your case conceptualization.

The confident-and-humble space—knowing a lot and not everything—never fully resolves. Senior therapists live in it too. What changes is that you develop a framework for navigating it. You know what you believe, so uncertainty about a particular client or moment doesn’t destabilize your entire professional identity. You have a compass. You don’t always know where you are, but you know how to orient.

Share Practice Forward

On Eclecticism—Because It Deserves More Than a Dismissal

The accusation against eclecticism is that it’s theoretical incoherence dressed up as flexibility—that “I pull from multiple frameworks” is often a way of avoiding the harder work of committing to a clinical worldview. There is something to this. When eclecticism means reaching for whatever technique feels applicable in the moment with no unifying theory underneath, it produces a clinical drift that clients feel even when they can’t name it.

But the critique gets used to shut down conversations the field genuinely needs to have. Rigid adherence to a single model isn’t clinical rigor—it’s often intellectual comfort. And the demand to “pick one and commit” can obscure a more important question: commit to what, exactly, and for whom?

It took time for me to reckon with the fact that several frameworks I was trained in carried assumptions about the self, health, and development that didn’t reflect the communities I was working with. That reckoning was uncomfortable—these were frameworks I’d invested in understanding. But it was also what deepened my orientation rather than destabilized it.

The distinction that matters isn’t eclectic versus committed. It’s integration versus diffusion. Theoretical integration means genuinely synthesizing compatible frameworks in service of a coherent clinical logic—with a clear rationale for why you’re drawing from each one and how they speak to each other. Theoretical diffusion is grabbing techniques from wherever they appear useful without a unifying theory underneath. Clinical flexibility isn’t having many techniques. It’s having a theory robust enough to hold complexity.

Can I explain why I’m doing what I’m doing, in terms of what I believe about this client and how people change? If you can answer that—you have a theory. Even if it doesn’t have a single name.

Share

Niching Down Without Theory Is Just Marketing

Specialization has real value—knowing your population, your clinical strengths, your areas of genuine depth. Done well, it makes you a better clinician and helps clients find the right fit.

The problem arrives when the niche precedes the theory.

Picture a clinician whose website lists EMDR, brainspotting, IFS, somatic therapy, mindfulness-based approaches, polyvagal-informed work, and attachment repair. A client comes in grieving the end of a twenty-year marriage.

Which framework is organizing the treatment? Which understanding of change is guiding the work? Which theory tells this clinician what this grief means, what might be maintaining the client’s suffering, and what conditions will allow them to move?

If the answer is “all of them”—it may actually be none.

That’s not a credential problem. It’s a conceptualization problem. No amount of training adds up to a theory of change if there isn’t a clinical logic connecting them.

When a client presents in a way that doesn’t respond to the first tool, there’s nothing underneath to fall back on. The clinician starts cycling through options—not because of clinical rationale but because they’re searching for something to land. The client, who came in not knowing what they needed, is now being asked to evaluate interventions they have no context for.

You lose credibility in that moment. But more than that, you lose yourself. You stop making informed decisions and become someone hoping something lands. That feeling eventually shows up in your retention numbers and in your own confidence. It’s the cost of building a practice identity before building a clinical one.

Share

The Worksheet Is Not the Work

New clinicians are handed a lot of objects. Handouts, scales, workbooks, homework assignments, structured protocols.

This is not an argument against structure. A thought record can be a brilliant intervention—exactly the right move for a client who needs to see their cognitive patterns made concrete. A carefully timed mindfulness exercise can create the regulation that makes deeper work possible. A well-placed worksheet can give a client a sense of agency they haven’t felt in a long time.

It can also be a sophisticated avoidance strategy. The worksheet itself doesn’t tell you which one it is. Only your understanding of why you’re using it—what it’s serving, in this moment, for this person, toward what end—does.

In supervision, I’ve watched the distinction play out in slow motion. A supervisee brings a session where a client, midway through, went quiet. Not the productive kind of quiet—the kind that feels like a door closing. The supervisee, sensing the shift, reached for their folder. Pulled out a thought record. Asked the client to identify the cognitive distortion.

The client filled it out. The session ended on time. No rupture, technically.

But what the supervisee was doing—and what took several supervision sessions to name—was managing their own anxiety about sitting in that silence. The worksheet wasn’t a clinical decision. It was an escape route. And the client, who had come into session with something real pressing at the surface, left with a completed form and nothing moved.

Ask yourself: in the sessions where you reached for an object, what were you trying to manage? Theirs—or yours?

What We Reach For

That question deserves more than a line.

I’ve done this too. Early in practice, when the room got uncomfortable in ways I didn’t know how to hold, I reached. Not always for a worksheet—sometimes for a reframe I knew intellectually was true but that wasn’t what the moment needed. Supervision helped me see it. My own therapy helped me feel it. What I eventually understood was that the reaching wasn’t a technique failure. It was a theory failure—I didn’t have a clear enough sense of what the discomfort was in service of, so I moved away from it instead of toward it.

In supervision and in my own practice, the moments when clinicians reach for rescue—introducing a tool not because it’s clinically indicated but because the room got uncomfortable—follow a recognizable pattern.

When a client gets close to grief, we teach coping skills. When a client gets close to anger, we introduce mindfulness. When a client sits in ambivalence and neither person knows what’s in it, we hand over a worksheet. When we’re uncertain what comes next, we generate a goal. When we’re anxious about whether we’re helping, we assign homework.

None of these are wrong as interventions. Every one of them can be wrong as anxiety management for the clinician wearing the guise of clinical work.

A thought record looks the same whether it’s the right clinical move or a way of filling space that grief was about to occupy. A mindfulness exercise looks the same whether it’s supporting regulation or redirecting attention away from an emotion that hasn’t been named. Psychoeducation looks the same whether it’s genuinely useful or whether it’s what we reach for when sitting with a client’s experience feels like more than we know how to hold.

The question isn’t whether you use structure. It’s whether you know, in the moment you reach for it, what you’re reaching toward—and what you might be reaching away from.

That awareness comes from theoretical grounding. From having a clear enough sense of what the work is for that you can distinguish between “this is clinically indicated right now” and “I am managing my own discomfort and calling it treatment.”

Early in your career, you will confuse the two. Every clinician does. The goal isn’t to never confuse them—it’s to develop the reflective capacity to notice when you have, and to use that noticing as information rather than evidence of inadequacy.

Subscribe now

What Clients Are Actually Looking For

When a client sits down with you, they don’t know what theoretical framework would serve them best or what case conceptualization means. What they know is that something isn’t working and they’ve come to someone with a perspective on that.

Your job isn’t to tell them what to do. But it is to bring something—a framework, a working hypothesis—that helps them make sense of themselves more clearly than they could alone. That’s not authoritarianism. That’s the job.

There’s a longer conversation to be had about what clinicians are meant to bring into the room and what they’ve historically been told to withhold. [For a related read: Rage Against the Blank Slate.]

When you offer a string of interventions without a through-line, clients experience professional uncertainty that undermines the foundation you’re trying to build. They came because they didn’t know where to start. If you don’t know either, you’re two people not knowing together.

That’s not therapy.

Leave a comment

They’ve Already Done the Research

Here is what will only become more true over time: clients are arriving pre-loaded.

Before they’ve sat with a clinician for the first time—or while they’re currently sitting with one—they’ve been deep in IFS subreddits, watching YouTube explainers on anxious attachment, following wellness influencers who post downloadable worksheets between sponsored content, and listening to celebrities describe their EMDR breakthroughs in podcast interviews. They’ve taken the attachment style quiz. They know what a “part” is. They’ve heard of the window of tolerance. Some can speak the language of multiple frameworks with apparent fluency.

Content that normalizes therapy and reduces stigma does something meaningful, especially for communities that have historically been excluded from or harmed by mental health systems. But knowing the language and understanding the framework are not the same thing. And a framework is not the same as a clinical application of one to a specific person, in a specific moment, inside a specific history.

A client who arrives convinced they are “anxiously attached” may be right. They may also be applying a lens that doesn’t account for the full complexity of their relational history, or being used to intellectualize rather than feel, or fitting the vocabulary of one relationship while obscuring the dynamics of another. A client who has done significant IFS work through social media may have genuine insight into their internal system—or may have developed a sophisticated way of narrating their experience that keeps the somatic and relational reality at a comfortable distance. The content can’t tell the difference. You can.

A clinician without theoretical grounding cannot navigate this well. They either validate whatever framework the client arrived with because it feels collaborative, or push back without being able to articulate why. A clinician with theoretical grounding can meet the client where they are, hold the language they bring without being bound by it, and use their own orientation to assess what’s actually clinically relevant. That’s not correcting the client. That’s the work.

As the volume of therapeutic content grows, clients will arrive with increasingly sophisticated partial knowledge. The clinician who has developed their own theoretical grounding will be able to contextualize and hold what the client brings. The one who hasn’t will find themselves in a difficult position: less informed than the client thinks they are, unable to differentiate between what’s clinically relevant and what’s well-marketed.

Change Has a Price—and They Already Know It

What tends to get skipped in the technique conversation: change is costly. Even when clients genuinely want it. Even when they intellectually understand what they’re working toward.

The patterns that bring people into therapy are rarely arbitrary. They developed for reasons. They solved problems—sometimes in early environments where options were limited, sometimes in more recent ones where better options existed but weren’t visible yet. The symptom was, at some point, a solution. And some part of the client knows that dismantling it means disrupting something that has, however expensively, been working.

Resistance is not irrational. It’s exactly what you’d expect when someone is being asked to give up a coping strategy that has offered them something—even something costly, even something they’ve outgrown.

A clinician grounded in their theoretical orientation understands this—not just as a concept, but as a felt sense in the room. They can name it: gently, precisely, without pathologizing the client for having it. And they can sit with the grief that comes with the possibility of change. The grief of the self that had to develop those patterns in the first place. The grief of what those patterns protected. The grief of what will be lost when they’re no longer needed.

That is not worksheet work. That is not technique work. That is the work that only a grounded, theoretically rooted, relationally present clinician can do.

Before Your Next Session

The essay closes where it started: with you, in the room.

Before you sit with your next client, try holding these questions.

What do I believe is maintaining this client’s distress right now?

What do I believe would create movement?

Why am I choosing this intervention—and not another?

If I couldn’t use a worksheet, psychoeducation, or homework today, what would I be listening for instead?

You don’t need perfect answers. You need honest ones. They’ll tell you more about your theoretical grounding than any training you’ve completed—and they’ll show you exactly where the work of building it continues.

The Ground Beneath Your Techniques

Most clinicians don’t find their orientation. They build it—through reading and supervision, through their own therapy, through every client who refused to fit neatly inside the theory they brought into the room. It grows as you do. It changes as you accumulate clinical experience that complicates the frameworks you started with.

To the clinicians I supervise: that strange space—knowing a lot and not everything, confident and uncertain at once—is not a problem to be solved. It’s the condition of doing serious clinical work. Senior therapists live in it too. What changes is that you develop a framework for navigating it rather than being lost inside it.

Develop your theoretical orientation seriously, and it will be there when the session gets hard and you don’t know what comes next. Not to hand you an answer. To give you a way of understanding what you’re seeing.

The answer you give today to “what do you believe about how people change?” does not have to be the answer you give ten years from now. Orientation is not a destination. It’s a developing position—one that becomes more nuanced and more genuinely yours the longer you stay curious about it.

But it has to start somewhere honest: with what you actually believe, not what you’ve been trained to deliver.

From that ground, the techniques stop being guesses. They become choices—deliberate, informed, made in service of a person whose inner life you’ve taken the time to map.

And what becomes available once you stop reaching for rescue is something no worksheet can provide: presence. The capacity to stay in the room with what is actually happening—not managing it, not escaping into task, but remaining with a person in the full weight of what they brought. That is what clients carry with them. Not which modality you used. Not what homework you assigned. Whether you were actually there.

Or more accurately, the takedown of the blank slate is having a moment. The tabula rasa is getting canceled.

That thing so many of us were taught in graduate school—or at least, what we thought we were taught. The version that gets mocked in reels and quote posts usually looks like this: sit still, reveal nothing, be neutral, erase yourself from the room. The clinical face of a marble statue. The joke practically writes itself.

And look—I get the frustration. I really do. There is something genuinely limiting about a model of therapeutic presence that flattens the clinician into furniture. But I’ve started to wonder if we’re raging against something we never fully understood. And if we never understood it, we might be throwing out the architecture while complaining about the wallpaper.

So let’s go back. Let’s actually look at where this idea came from, why a generation of supervisors taught it, and what they might have actually meant. Because I don’t think they meant your face.

Where the blank slate actually came from

The phrase has roots that go all the way back to Aristotle, who described the mind as an unwritten tablet shaped by experience. But it was John Locke who gave it teeth in 1690, in An Essay Concerning Human Understanding. Locke’s argument was a philosophical one, not a clinical one: that we are not born with innate ideas, that knowledge arrives through experience, through sensation and reflection. The mind, in his framing, begins empty—and the world writes on it.

This was radical at the time. It was a direct challenge to the Cartesian belief in innate knowledge, in fixed ideas baked into the soul at birth. Locke’s blank slate was, at its heart, an argument for human possibility. If we’re shaped by experience, then experience can be changed. The slate can be written on differently.

That idea moved through philosophy and eventually landed in early psychology, where it became the intellectual foundation for behaviorism. Watson, Skinner, the whole conditioning tradition—they took Locke’s logic and ran with it. Humans are shaped by environment. Behavior is learned. Nothing is fixed. Watson famously and absurdly claimed he could take any infant and train them toward any outcome given the right conditions. An extreme version, yes. But it came from a lineage with legitimate philosophical weight.

Early psychotherapy picked up what behaviorism left behind. The learning history mattered. What got reinforced. What got punished. The implicit message was: change is possible, because nothing is written in stone.

That’s the origin story. And notice what it was never about: your self-disclosure habits. Your facial expressions. Whether you nod. Or even have that tasty little treat in session.

Share

Here’s where it gets interesting: Freud didn’t believe any of it

There’s a wrinkle in this history that almost never gets taught alongside the blank slate concept, and it matters.

When psychoanalysis arrived, it borrowed the posture of the blank slate without subscribing to the philosophy of it. Freud’s famous setup—patient on the couch, analyst seated behind and out of view—was not an expression of Lockean empiricism. It was something altogether different: a deliberate structural choice designed to minimize the therapist’s visible influence, reduce the client’s social performance, and allow something called transference to emerge. By becoming less visually present, Freud theorized, the therapist becomes a kind of screen—a surface onto which the client’s internal world gets projected outward, where it can then be examined. (…Or maybe Freud was just shy and didn’t want to maintain eye contact for so long.)

That’s actually a sophisticated clinical rationale. And it is not the same thing as believing people are blank slates.

Because Freud did not believe people were blank slates. He believed the opposite. His entire theoretical framework rested on the idea that we arrive already structured—with innate drives, with an unconscious that is active and conflicted from the start, with developmental pressures that move through us whether we name them or not. Where Locke said the mind is written on by experience, Freud said the mind already has its own grammar. Experience doesn’t write on an empty page. It interacts with forces already in motion.

The distinction matters more than it might seem: Locke’s blank slate belonged to the person. Freud’s blank screen belonged to the therapist.

Which means the clinicians pushing back on it now are in good company. Freud was skeptical of it too—and he’s been dead since 1939.

The rejection of the blank slate isn’t a new idea. It was present at the founding. What’s new is who is asking the question, whose clients are in the room, and what the stakes look like now. And that matters enormously. But it’s worth knowing you’re entering a very long conversation, not starting one.

Subscribe now

What your professors (probably) meant

Here’s my honest read, over a decade into this field, having been taught by that generation and having supervised clinicians coming out of programs still steeped in it: when supervisors invoked the blank slate, they were usually trying to teach something specific and actually important.

They were trying to say: don’t make this about you.

Don’t center your reactions. Don’t let your comfort or discomfort steer the session. Don’t project your history onto your client’s story. Don’t assume. Come in without a verdict already written. Stay curious longer than feels comfortable. Let the client write the story before you start interpreting it.

That’s actually a sophisticated clinical principle—one that trauma-informed, culturally responsive work depends on. When we talk about the dangers of a clinician who enters the room already knowing what’s wrong, already mapping a client onto a familiar template, already filling in blanks that haven’t been offered yet—we’re naming the failure state that the blank slate was trying to prevent.

The problem wasn’t the concept. The problem was the translation.

Somewhere between Locke and the supervisory chair, “don’t make it about you” became “erase yourself.” “Stay curious” became “don’t react.” “Suspend your assumptions” became “perform neutrality.” The nuance got squeezed out in training, and what remained was a posture that looked more like dissociation than presence.

That’s a training failure. It’s not an indictment of the entire philosophical framework underneath it.

Share

And yet—the pushback makes complete sense

Here’s where it gets genuinely complicated, and why I think the defensiveness isn’t just social media noise. There’s a reason the blank slate teaching hits wrong for so many clinicians, and it’s not simply that we misunderstood it.

It’s that we were also taught something else. Something that sits in direct tension with it.

We were taught—in the same programs, sometimes by the same supervisors—that therapy is a relational process. That the therapeutic relationship is not incidental to healing. That it is the mechanism of healing. Rogers told us that. Bowlby’s work on attachment told us that. Every relational and humanistic tradition in our field told us that the corrective emotional experience—the thing that actually moves the needle for many clients—happens between two people, not just inside one of them.

You cannot have a genuine relationship with a blank slate. You cannot have a corrective emotional experience with furniture.

No wonder there’s defensiveness. No wonder there’s rage. When a concept feels impossible to embody—when you’ve spent years trying to be both invisible and transformative, both erased and genuinely present—frustration is the appropriate response.

Trying to be a blank slate doesn’t remove you from the relational field. It just makes you less aware of how you’re in it.

And that unawareness is actually the danger. A clinician who believes they’ve achieved neutrality isn’t neutral—they’re just less likely to notice when their reactions are steering the session, when their discomfort is contracting the space, when their need to be seen as the good, helpful, non-reactive therapist is quietly shaping what their client feels safe to bring.

The relational tradition didn’t just complicate the blank slate. It exposed the impossible ask underneath it. And I think the clinicians pushing back on social media are, at their core, defending something true: that you cannot take yourself out of a human process without making it less human. That presence is not a liability. That the self of the therapist is not a contaminant to be managed, but a resource to be understood.

They’re right about that. The blank slate, as it was often taught and practiced, asked us to disappear in a room where showing up is the whole point.

The problem is that “show up fully” without further architecture is also not a clinical framework. Which is why we need something more precise than either pole.

Share

What the blank slate got right—and where it ran out of road

Here’s what we should keep: the blank slate tradition handed us something genuinely liberating.

• It said that what happens to people matters.

• That environments shape outcomes.

• That change is possible precisely because nothing is entirely predetermined.

In a field that needed to move people toward hope, that was meaningful.

It also helped us develop tools we still use—behavioral interventions, reinforcement-based approaches, the understanding that patterns can be unlearned. CBT owes a significant philosophical debt to this lineage. So do many exposure-based trauma treatments.

Neuroscience has been clear for decades now: we are not born empty. We arrive with temperament, with biological predispositions, with a nervous system already primed for certain responses. Attachment researchers showed us that we are wired for relational connection before we can speak. Chomsky blew a hole in pure behaviorism by pointing out that language acquisition cannot be explained by conditioning alone—something in us is already structured to receive it.

And culturally responsive work makes the most important critique of all: the blank slate assumption is never culturally neutral. The idea that we enter experience without prior content is itself a product of a specific historical and cultural moment. It assumes a kind of generic, unmarked human subject that does not exist. You cannot practice culturally responsive therapy and also believe that you—or your client—arrives as an empty vessel. Identity, history, power, and context are always already in the room.

Too much blank slate thinking risks erasing precisely the things that matter most: who your client actually is, what systems have shaped them, and what you yourself bring to the encounter.

What a new generation of clinicians actually hears

Something gets lost when old Latin gets handed to new clinicians without context.

Tabula rasa. The blank slate. The neutral stance. For a generation of therapists trained in the last decade—many of whom came to this field specifically because they wanted to work with communities that had been failed by it—these phrases don’t land as philosophy. They land as instruction. And in the context of who is sitting across from them in the room, they land as something closer to erasure.

Consider what it means to be a clinician trained in neutrality when your client is a first-generation immigrant who has spent their entire life being the translator—the one who has always had to translate themselves for rooms that weren't built around them. A neutral stance in that room doesn’t feel like open space. It feels like one more person waiting to be convinced.

And when a client who holds multiple, intersectional marginalized identities within their community discloses something that is not just personal but also political—something about their body, their safety, their right to exist in certain spaces—a carefully balanced reflection doesn’t protect the therapeutic frame. It replicates the exact conditions the client came in exhausted from: being in a room where the labor of articulating what's wrong—and why it matters—lands entirely on the person who came in already carrying it.

This is what the new generation of clinicians is reacting to when they push back on blank slate thinking. Not the philosophy. Not the original intention. They’re reacting to what neutrality actually feels like to certain clients in certain rooms at this particular moment in time—when identity is being legislated, when communities are being targeted, when the distance between the clinical and the political has never felt thinner.

And they’re not wrong.

Neutrality was always a cultural artifact, even when it presented itself as the absence of one. The idea of the objective, unmarked clinician—present but not positioned, attentive but not located—reflects a very specific set of assumptions about who the default human subject is. It was built on an implicit center. And anything built on an implicit center tends to protect that center without meaning to. (And, on a process level, perceived neutrality can be interpreted as dismissiveness, disinterest and detachment to a client. Just be prepared to address this in session).

When therapists who came up in predominantly white, Western clinical training traditions taught the blank slate and neutrality as the professional standard, they were also—without realizing it—teaching a particular cultural stance as though it were no stance at all. That’s not about intention. It’s about architecture. The blank slate concept, as it filtered into clinical education, absorbed the cultural assumptions of its moment. And those assumptions had a center that many clinicians and clients were never inside.

So the rage on social media? It’s not really about the concept. It’s about what it felt like to be handed a framework as though it were universal, and then to sit across from a client whose reality it couldn’t hold.

The blank slate doesn’t just have limits as a theory. In certain rooms, with certain clients, it has costs. And those costs have not been shared equally.

That’s what needs to be said alongside the history. That’s what the new generation is trying to name, even when the critique gets flattened into a reel.

Subscribe now

If we’re not blank slates, then what are we?

This is the question I keep turning over. Because the social media critique is right that the marble-statue model of the therapist doesn’t serve our clients. But the alternative can’t just be “bring your whole unprocessed self into the room and call it authenticity.” That’s not a clinical framework. That’s a recipe for harm with better branding.

So I want to offer a different image. Not blank slates. Not open books. Something more like this:

We are instruments.

That’s what I think we’re doing in this work.

We are not blank. We came in with a history, a nervous system, an attachment style, a cultural location, a set of values we didn’t fully choose. We were shaped by every supervision session, every personal therapy appointment, every client who cracked something open in us. We have grain. We have resonance. We have limits and capacities that are distinctly ours.

The question is not how to erase all of that. It’s how to know it well enough to use it in service of someone else’s healing—rather than letting it run the session without our awareness.

The work isn’t to become a blank slate. The work is to become a known instrument.

What this means for how we teach

I think we owe our students a more honest account of what we’re actually asking for when we teach about therapeutic presence. Not neutrality as performance. Not the erasure of self as proof of professionalism.

That’s not the blank slate. It never was.

It’s something harder, actually. It requires more of us, not less. It asks us to be deeply present and deeply boundaried at the same time—to bring our whole instrument to the session and to play it with enough discipline that it doesn’t drown out what we came to hear.

The blank slate was a starting point in a much longer conversation about what therapists are and what we owe our clients. It’s okay to have moved past it. It’s worth understanding what it was trying to say before we leave it behind.

Original post.

I’m one of many therapists with opinions on the internet. I post, people engage, we move on. This one was different.

The DMs came in waves.

First, the vendors—people selling clawback solutions, billing software, financial management tools, practice consultants with a service for exactly my problem. I don’t say that with contempt. Some of those tools are genuinely useful. But that’s not who I wanted to talk to.

The messages I kept coming back to were from new professionals. Clinicians early in their careers, some still in graduate school, trying to figure out whether to take insurance at all—and now a little spooked. They wanted to understand what had actually happened to me, whether it could happen to them, and what the real picture of insurance participation looks like before they sign anything.

And then there were the clinicians who are already paneled, already in it, quietly wondering whether the arrangement still makes sense for the practice they’re running now.

This is for both of you. My thought process, the honest pros and cons, what to consider before you decide, and the realities that tend to surface once you’re already in it.

In the interest of full transparency: I take insurance. Two plans specifically—BCBS and Tricare. In DC, where federal employees and military families make up a significant portion of the population, those two cover a lot of people. More than a decade ago, a therapist mentor I trusted recommended I panel with both, and I did. I don’t regret it. It shaped my practice in ways I value. But I also came into it without the full picture, which is exactly why I’m writing this now.

One thing I want to name before we go any further: this is not a piece designed to talk you out of private practice. Building your own practice is worth pursuing, and people do it successfully every day—with insurance, without it, and everywhere in between. What it requires is clarity. The more you understand the system you’re entering, the more agency you have inside it. That’s what this is for.

Your contract reflects your license, not your résumé

In most traditional outpatient behavioral health contracts, reimbursement is driven far more by licensure category and payer fee schedules than by years of experience, postgraduate certifications, or specialty training. That EMDR certification you invested hundreds of hours and several thousand dollars in? Clinically meaningful, absolutely. On most insurance contracts? Invisible.

This matters for how you think about the financial return on continuing education. The professional development case for additional training is real and worth making. The income case, if your primary revenue is insurance-based, is much harder to make.

Getting paneled takes longer than you think—and there’s a database you need to know about

Before you submit your first claim, you have to get credentialed. That process is slower than most new clinicians expect—typically three to six months, sometimes longer depending on the payer, your licensure state, and how complete your application is when you submit it.

Many major commercial insurers require you to maintain a profile through CAQH—the Council for Affordable Quality Healthcare—a centralized credentialing database that payers use to verify your information. Create your profile early, keep it current, and re-attest regularly. Letting it lapse creates delays that are entirely preventable.

Plan for the credentialing window before you need the income. Building a caseload while waiting to be fully credentialed is a real financial exposure that doesn’t get talked about enough. Some insurers will credential pre-licensed clinicians under certain conditions—supervision arrangements, specific licensure types, payer-by-payer policy—so if you’re not yet fully licensed, it’s worth asking directly rather than assuming the door is closed.

“Fast payment” is relative

If everything goes right—clean claim, no errors, correct codes, correct modifiers, correct rendering provider information—you’re often looking at anywhere from several days to several weeks before payment lands, depending on the payer.

If something is off, that timeline extends. A mismatched NPI, a missing authorization number, an incorrectly applied diagnosis code—any of these can send a claim into purgatory. You may not find out there’s a problem until you notice the payment never came, which means you’re already weeks behind before you’ve even started fixing it.

This is the part of the administrative burden that doesn’t fully register until you’re in it. You’re not just submitting claims. You’re tracking them. Following up on them. Calling payer lines. Resubmitting. Appealing. Often while also writing clinical notes, managing scheduling, and doing the actual therapy.

Share

About negotiating your rates—and why you may not know what your colleagues are getting

You’ve probably heard that you can request a rate increase once a year. That’s technically true for many contracts, and the process varies by payer. What doesn’t get mentioned as often is how rarely it results in meaningful change.

Rate increases happen. They are not common. When they do occur, they tend to be modest—a few dollars per session, if that. Not nothing, but rarely the kind of shift that restructures your financial picture. Go in with realistic expectations, keep your request professional and documented, and understand that the outcome is largely outside your control.

There’s another layer to this that fewer people talk about openly: individual provider contracts sometimes include confidentiality or non-disclosure language around reimbursement rates—language that may discourage or restrict sharing what you’re getting paid with colleagues. Federal law has shifted some of this; certain gag provisions that restrict disclosure of price and quality information by plans and issuers are now prohibited. But what’s enforceable still varies by contract, state, and circumstance. The practical upshot is that you may have limited visibility into whether your rate is competitive, equitable, or significantly below what someone with your same license type is receiving across town. Read what you’ve signed. And if the language is unclear, it’s worth asking a healthcare attorney before assuming what you can or can’t discuss.

Clawbacks: what they are, why they happen, and how to protect yourself

My LinkedIn post was about this, and it’s worth going deeper.

A clawback—or recoupment—happens when an insurance company determines, after the fact, that a claim was paid in error or that documentation doesn’t support the services billed. They can occur months or years after services were rendered.

The claim was processed. You were paid. You moved on. And then a letter arrives.

Common triggers include audits, beneficiary eligibility issues discovered retroactively, documentation that doesn’t align with billed service codes, and payer policy changes applied backward in time. Some of these are administrative errors on the payer’s end. Some are documentation gaps on yours. Some are genuinely contested. All of them land in your lap.

Keep your clinical documentation thorough and tightly aligned with what you billed. The standard effectively becomes whether your documentation can withstand payer review or audit scrutiny.

Set aside a reserve. Treat a percentage of insurance income as untouchable—held specifically for recoupment scenarios. How much depends on your volume and risk tolerance, but having something set aside means a notice like the one I received is a problem to manage rather than a crisis to survive.

If you receive a recoupment notice, you typically have the right to appeal. Do not simply pay it without reviewing the claim in question. Request the specific reason, pull your documentation, and consult a healthcare attorney if the amount is significant or the reasoning is unclear.

(It’s a bear…get it? Claw…backs…heh…)

Verify eligibility. Every time. Even when you think you know.

Most practices have a policy: clients are responsible for notifying you when their insurance changes. Put it in your intake paperwork, review it at the start of treatment, make it part of your financial agreement. That policy matters and you should have it.

It will not protect you the way you think it will.

Clients forget. They don’t fully understand that a job change mid-month means their coverage changed mid-month. They get married and assume the plan automatically updates. They lose a position and don’t realize their COBRA window has already started ticking. They’re not being careless—they’re managing their lives, and insurance logistics aren’t at the top of the list.

The claim you submit in good faith against a plan that lapsed three weeks ago is still a claim you’ll be chasing.

If you know something has shifted in a client’s life—a new job, a change in employment status, a marriage, a move—verify before the next session, not after. Most EHRs have eligibility checking built in, and many payers allow real-time verification. Build it into your intake workflow and your clinical radar.

The clinical constraints no one puts in the brochure

The financial and administrative picture is only part of what shapes how clinicians feel about insurance participation. The clinical picture matters too—and for many therapists, it’s ultimately the deciding factor.

Insurance reimbursement is tied to CPT codes: a standardized set of billing codes that describe clinical services in broad strokes. What many new clinicians don’t realize is that the labels on those codes and the actual reimbursable time are not the same thing. A “60-minute session” billed under 90837 is actually reimbursable starting at 53 minutes—not 60. A “45-minute session” under 90834 covers 38 to 52 minutes. A “30-minute session” under 90832 covers 16 to 37. This is why many therapists schedule sessions at 53 to 55 minutes—it satisfies the criteria for the 60-minute code while leaving a few minutes for notes, transitions, and the administrative reality of running a practice. It’s not a workaround. It’s just how the system actually works, and knowing it early saves a lot of confusion later.

The codes themselves are blunt instruments regardless of the time ranges. They don’t capture the nuance of the work, the modality, the relational complexity, or the clinical judgment involved in any given session. Many experienced therapists find that over time, organizing their documentation around code justification rather than clinical thinking starts to feel like it pulls them away from the work rather than toward it.

Couples and family therapy adds another layer of frustration. Work billed under 90847—couples or family therapy with the identified patient present—is often reimbursed at lower rates than individual therapy, despite the fact that the clinical complexity is frequently higher. You’re managing multiple nervous systems in the room, navigating attachment dynamics, doing active conflict mediation, and writing documentation that accounts for all of it. Many therapists and billing professionals openly criticize this discrepancy, and they’re not wrong to.

The deeper issue is structural. Insurance is built around a medical model that requires an identified patient with a diagnosable condition and documented medical necessity. Reimbursement and medical necessity standards for relational distress alone are inconsistent across payers and often more restrictive than for individual diagnoses—which means clinicians doing couples work through insurance regularly find themselves navigating ethically uncomfortable territory. Questions like who is technically the patient, whether they’re treating a person or a relationship, and whether billing through insurance requires pathologizing one partner in order to justify care at all. It’s one of the more quietly corrosive tensions in the field, and it’s a significant reason why many couples therapists eventually move to private pay or hybrid models entirely.

There’s a related tension that runs through insurance-based practice more broadly and rarely gets named directly: the pressure toward medical necessity documentation can create subtle incentives to frame distress in increasingly clinical language in order to maintain reimbursement. Insurance systems are built around demonstrating ongoing need, which over time can shape how clinicians conceptualize and document care—emphasizing symptom persistence and impairment over complexity, context, or growth. The tension isn’t always dramatic. But it accumulates, and it’s worth knowing it exists before you’re inside it.

Add-on codes are another layer worth understanding. These are supplementary billing codes used alongside a primary service code to reflect additional clinical complexity within the same session—certain psychotherapy add-on codes, such as interactive complexity codes, are examples. For a period, billing certain add-on codes was a legitimate way to more accurately capture the work and receive slightly higher reimbursement. Then, several years ago, some of my plans simply stopped accepting them. No gradual phase-out—the code that had been reimbursing cleanly was now either denied or ignored, and the income I’d built into my projections based on that billing pattern quietly disappeared. Payers can change what they accept, what they reimburse, and how they process codes—often with minimal notice—and your financial planning needs to account for that variability.

None of this means insurance participation is the wrong choice. For many clinicians it’s the right one—and a sustainable one. What it means is that the decision deserves more than a default. The rest of this piece is about helping you make it deliberately.

You don’t actually have to take insurance

One of the arguments most commonly made for paneling is that it expands access—that being in-network with major payers helps clients who couldn’t otherwise afford care. That’s true, and it’s a legitimate values-based reason to participate.

But insurance panels are not the only path to accessible, equitable care.

A thoughtfully designed sliding scale—one with real flexibility built in, not a token lower tier—can serve clients who need reduced fees. Community partnerships, reduced-rate spots held intentionally, clear communication about financial options: these create access too. And increasingly, newer clinicians are using content, community, and social media to reach clients and build referral networks in ways that don’t depend on directory listings at all.

There’s also a middle path worth knowing about: out-of-network practice with superbill reimbursement. If you choose not to panel but your clients have out-of-network benefits, you can provide them with a superbill—an itemized receipt with the clinical codes their insurer needs—and they can submit it for partial reimbursement directly. It doesn’t work for every client or every plan, and it shifts the administrative burden to the client rather than eliminating it. But for some practices and populations, it’s a meaningful option that often goes unmentioned in the paneling-versus-private-pay conversation.

Being paneled funnels certain clients to you because you show up in their network’s search results. There are other ways to be findable, to serve broadly, to build a practice that aligns with your values. The panel is one path. Ask yourself whether it’s the right one for where you are right now.

The administrative weight is real—and it compounds

Writing notes. Completing treatment plans. Keeping documentation compliant with payer requirements. Submitting claims. Tracking claims. Following up on unpaid claims. Calling insurance companies. Appealing denials.

This is not a small addition to a clinical workload. For some clinicians, it’s sustainable—especially with solid billing support or EHR tools that streamline the process. For others, the weight of it chips away at the part of the work they actually entered the field to do.

There’s a whole industry around billing support, and if you’ve spent any time in practice owner spaces, you’ve seen the offers. Many billers charge a percentage of what gets collected—somewhere between five and ten percent is common, though it varies. EHRs are increasingly offering their own billing services too, which can feel appealing since everything lives in one place.

Before you commit to any arrangement, run the numbers carefully. You’re already accepting a contracted rate below your full fee. Credit card processing takes a percentage. Your EHR has a monthly cost. Liability insurance, consultation, continuing education, the cost of your space—all line items. A billing percentage on top of all of it can leave you with less than you’d expect. Know your effective rate after every deduction. If the math works and the time you reclaim is worth it, the arrangement makes sense. If it doesn’t, no amount of convenience changes that.

Two things you cannot do—and why they matter

No, you cannot write off the difference between your full fee and the insurance-allowed amount as a business loss. The contracted rate is the agreed-upon rate. The gap between that and your private pay fee isn’t income you lost—it’s income that was never owed under the terms of the contract.

And no, you cannot bill the client for that difference. This is called balance billing, and for in-network providers, it’s generally prohibited by your provider contract.

Here’s how it works in practice. Say your full fee is $200 per session. The insurance company’s allowed amount is $120. They pay $90, and the client’s coinsurance covers $30. That $120 is your payment in full. The remaining $80 is not collectible from the client—not as a balance, not as an administrative fee, not in any form—as long as you’re in-network with that payer.

Attempting to collect it can trigger contractual violations, recoupments, audits, and in serious cases, fraud concerns or licensing complaints.

The only permissible charges beyond what insurance pays are the client’s actual cost-sharing responsibilities: copays, coinsurance, and deductibles as defined by their plan. Everything else stays off the table.

And if you decide to leave a panel

Leaving a panel isn’t as simple as opting out. Most contracts require advance written notice—sometimes 60 days, sometimes 90, sometimes more. Read your contract carefully before you assume you can exit quickly.

Outstanding claims don’t disappear when your termination is effective. Any recoupment or audit activity tied to claims submitted during your in-network period can follow you past your exit date. Transitioning clients also requires careful handling—your contract and your ethics code both have something to say about continuity of care and how you communicate a change in your ability to accept their insurance.

None of this should stop you from leaving an arrangement that no longer serves your practice. It should make sure you leave it cleanly.

Before you decide, sit with these questions

Not a checklist. Just the questions worth answering honestly before you sign a contract—or before you decide not to. And if you’re already paneled: before you decide whether to stay.

On the financial reality:

Do you actually know what the contracted rate is for the codes you’d bill most? Pull it before you panel, not after. Then subtract processing fees, EHR costs, and whatever billing support you’d need—and look at what’s actually left.

If you own a group practice, do that math per clinician. Not on average. Per person.

On your capacity:

Be honest with yourself about documentation. Not whether you can do it—you can—but whether insurance-level documentation is something you’ll sustain without it quietly eating at you. There’s a difference between notes you write because the clinical work calls for it and notes you’re writing to satisfy a payer audit that may or may not ever happen.

And the phone calls. The follow-up on denied claims. The eligibility checks. When you picture that being a real part of your week, does it feel manageable or does something in you resist it? That reaction is information.

On clinical fit:

Does the way you practice map reasonably onto how insurance expects you to document and bill? If you work in longer-term relational modalities, practice outside a symptom-reduction framework, or do significant couples or family work, that tension is worth naming before you’re managing it inside an active treatment relationship.

On access and who you’re actually trying to reach:

Do the clients you most want to serve need you to be paneled specifically—or do they need you to be affordable and accessible? For clients with high-deductible plans, the out-of-pocket cost of seeing an in-network therapist can be surprisingly close to a private pay rate, especially early in the plan year. The “insurance makes care affordable” equation isn’t always as clean as it sounds.

On where you are in your practice:

If you’re newly licensed, the referral pipeline from paneling has real value. But so does building direct relationships and establishing yourself in a niche. The question is which one fits how you actually want to spend the time that isn’t clinical.

If you’ve been in practice for a while: when did you last look at whether your insurance contracts still make sense for the practice you’re running now versus the one you were building back then?

On your risk tolerance:

Do you have a financial cushion that could absorb a recoupment notice—something unexpected, potentially in the four figures—without it becoming a real problem? If not, is building that cushion something you could do on insurance income, or does the tighter margin make it harder?

These aren’t gotcha questions. They’re the ones that tend to come up anyway, usually at a less convenient moment.

Share

There’s no single right answer at the end of all this. Some of you will work through these questions and feel confident that paneling makes sense for where you are. Others will realize the math doesn’t hold, or that the clinical constraints are too significant, or that the administrative weight isn’t where you want your energy going.

Both are legitimate outcomes. The goal is just to make sure the decision is actually yours—made with information, not assumption.

If you’re early in your career and reading this feeling more uncertain than when you started—that’s okay. That uncertainty is doing something useful. It’s asking you to think carefully about the infrastructure of the thing you’re building, not just the clinical vision of it. And the clinical vision is real. The desire to serve people well, to build something meaningful, to create a practice that reflects your values—that doesn’t go away because the business side is complicated. It just means the business side deserves your attention too.

Private practice is hard to build. It’s also built every day, by clinicians at every stage, with every combination of choices about insurance and access and structure and modality. There is no single blueprint that works for everyone. There is just the work of understanding your options clearly enough to choose among them.

Have a question you’d like answered in a future post? Drop it in the comments.

Leave a comment

A note for those thinking further ahead: building a group practice

If a solo practice isn’t the end of your vision—if you’re already thinking about bringing on other clinicians, even as a distant someday plan—there are insurance considerations that compound at the group level. You don’t need to solve for these now. But knowing they exist will save you from building toward something and finding structural obstacles you didn’t anticipate.

• A contracted rate that sustains you as a solo clinician may not sustain a group model. Once you factor in a clinician’s split or salary, billing support, credentialing costs, EHR seats, supervision, and payroll taxes, the same reimbursement rate operates very differently. Run the full per-clinician cost picture before you hire, not after.

• Individual clinicians carry a Type 1 NPI; group practices bill under an organizational Type 2 NPI. Payers often require separate enrollment and credentialing steps for each provider in the group—these are distinct processes with their own timelines and requirements.

• Do not assume your current contracts, rates, or credentialing status transfer automatically when you change structure, tax ID, group affiliation, or add clinicians. Payer contracts are not always portable, and what applies to you as a solo provider may not apply to your practice as a group entity.

• Rate structures vary by payer. Some contracts apply the same fee schedule across all clinicians in a group; others vary by license type, provider taxonomy, supervisory status, or service site. Verify for each payer rather than assuming consistency.

• Clawback exposure scales with volume. More clinicians means more claims, more documentation variation, and more audit surface area. Documentation standards need to be consistent across your entire practice, not just your own caseload.

• Supervised and pre-licensed billing is one of the most common areas for denials and recoupments when not handled correctly. Whether a payer allows billing under a supervisor’s NPI—and under what conditions—varies by payer and state. Check each payer’s specific supervisory billing guidance before assuming it’s permitted.

• Administrative overhead grows faster than headcount. What one person managed on the side often requires dedicated billing support by the time you have three or four clinicians. Build that cost into your projections before you need it.

Again, none of this is meant to discourage growth. It’s meant to make sure the infrastructure decisions you make now don’t create problems you have to unwind later.

And then nothing. No follow-up. No roadmap. Just speaking engagements, floating there like it’s self-explanatory.

I understand the impulse to suggest it. It’s a real option. But the gap between that comment and actually knowing how to break through as a speaker can feel enormous—especially when you’re already stretched thin trying to figure out how to sustain a practice.

I’ve done a number of speaking engagements over the years. I want to be honest with you upfront: it’s not something I actively rely on as income, and it’s not something I pitch myself for regularly. I know therapists who do—who track calls for proposals, submit to conferences consistently, build their visibility intentionally. That’s a legitimate path. But it’s not the only one, and it wasn’t mine.

What I’m offering here is a behind-the-scenes look at how this has unfolded for me—not a blueprint with guaranteed results, and not a prescription for how it should unfold for you. My ramp-up was a cumulation of years of practice, small opportunities, gradual confidence-building, and a fair amount of stumbling. Others come at this more assertively—pitching themselves consistently, developing a signature talk early, building a speaking brand with real intention. That approach works too. There are multiple valid paths in. I can only speak honestly about the one I’ve been on.

My start was considerably less polished. I was a graduate student, standing nervously in front of a poster at my state counseling conference—answering questions one or two people at a time, hoping I could hold a coherent conversation about my work without visibly sweating. What I didn’t know then was that those moments were building something. Over a decade later, the ease I feel synthesizing information, sharing what excites me about a topic, holding a room—that came from those small, informal exchanges. The keynotes and the honorariums came much later. The poster session came first.

I share that because I think the entry point matters. If you’re genuinely not sure where to begin, start there: in your professional organization, your local community, your training program’s alumni network. Offer your time—thirty minutes, an hour—to speak on something you know well. It doesn’t have to be groundbreaking research or an original theory. The originality comes from your perspective, your clinical lens, the way you frame something that might otherwise feel inaccessible.

Accessible and compelling is its own kind of expertise.

A note on definitions before we go further.

When I talk about speaking engagements here, I’m referring to conference presentations, keynotes, panel appearances, and community talks—situations where you’re being brought in to share expertise with a live audience. Training is adjacent but distinct in my mind: it typically involves skill-building, continuing education credit, and a more structured facilitation role.

That said, the line isn’t always clean. I’ve been to conferences where a keynote or featured presentation was also approved for continuing education credit—which means the same talk that reads as a speaking engagement on your end is functioning as a training on the attendee’s end. It happens more than you’d think, and it’s worth knowing that your expertise can carry CE value even when you’re not designing a formal training curriculum. The distinction I’m drawing is less about the format and more about the intent: are you primarily there to share a perspective and move a room, or are you primarily there to build a skill? Both matter. They just require different preparation and different expectations going in.

For the purposes of this piece, we’re focused on speaking engagements—but if the CE conversation is something you want to explore further, that’s a whole other essay.

Share

Before you pitch anything: get clear on your lane.

This is the step most people skip, and it’s the one that makes everything else harder. Before you start reaching out to conferences or submitting to calls for proposals, you need to know what you want to be known for on stage—not “mental health” broadly, but something specific enough that when someone hears you speak once, they walk away understanding something differently than they did before.

That’s your signature lens. And it’s worth sitting with before you start saying yes to things.

For therapists, strong lanes often emerge from the intersection of who you serve, what you see every day in the room, and what you believe the field is still getting wrong. The clinician who works with bicultural families and has thought deeply about identity and belonging has something to say that a generic wellness speaker doesn’t. The supervisor who’s spent years watching training gaps play out in real clinical situations has a perspective that a textbook can’t offer.

You are not just a mental health professional. You are a particular kind of mental health professional with a particular vantage point. That vantage point is where your speaking life begins.

A useful prompt to sit with: If someone hears me speak once, what do they walk away understanding differently? That answer is your throughline.

The “two or three topics” question—and where I land.

There’s a common piece of advice in speaker circles: pick two or three topics, develop them deeply, and repeat them. Get so familiar with your material that you barely need your slides. The plus side is real—repetition builds confidence, and confidence is what makes a room lean in. A signature talk becomes shareable. It becomes your brand, the message people associate with you, the thing conference coordinators think of when a slot opens up.

But I tend to tailor my engagements to the event itself—the theme, the audience, the priorities the planning committee is working around. A cookie-cutter talk doesn’t always serve a room that has specific needs, and I’d rather arrive curious and prepared than efficient and generic.

These approaches aren’t opposites—they’re a spectrum, and most working speakers live somewhere in the middle. Build two or three core talks you know well, then adapt them for context without reinventing from scratch every time. The core throughline stays intact; the framing shifts to meet the room.

Try this: Draft a working title and a two-sentence description for one talk you could give right now. Don’t overthink it. What do you find yourself explaining to colleagues, supervisors, or students on a regular basis? That’s likely your first talk.

Start before you feel ready.

If getting in front of a room still feels like too much, start with an online presence. I love writing—and for me, that was its own kind of beginning long before I ever stood in front of an audience with intention. A newsletter, a blog, consistent posts about what you’re thinking about clinically. If someone reads it, wonderful. But that’s almost beside the point. At minimum, it signals what you care about, what you find worth discussing, what you’d show up to talk about if someone asked. It plants a flag. And sometimes that flag is what gets you invited into rooms you weren’t actively pursuing.

When you’re ready to be in front of people, one of the most underused entry points is also one of the most low-stakes: co-presenting. I did this regularly as a graduate student, and it made a meaningful difference in how comfortable I became in professional settings before I ever had to hold a room on my own. Find a colleague, a classmate, a supervisor—someone whose thinking complements yours—and submit together. You split the preparation, you split the nerves, and you get to watch how someone else handles the parts that feel uncertain to you. Conferences are often more open to proposal submissions than people assume, especially at the regional and state level. You don’t have to be an established name to get on a program. You have to have something worth saying and be willing to submit.

If a conference still feels like a stretch, offer to present at a colleague’s group practice, run a lunch-and-learn for a local nonprofit, or do a joint workshop with a friend to a room of ten people.

The audience size doesn’t determine the value of the practice. What you’re building is your relationship to being in front of people—the pacing, the pivots, the comfort with silence, the recovery when something doesn’t land the way you expected.

That only comes from doing it.

Before you can send anything: the basics you need ready.

Before a speaker kit, before a pitch email, before anything else—you need two versions of your bio. Not because it’s glamorous prep work, but because you will be asked for both, often with little notice, and scrambling to write about yourself under a deadline is its own particular misery.

• Your short bio is typically two to four sentences—the version that appears in a conference program, gets read aloud before you take the stage, or sits beneath your headshot on an event webpage. It should include your credentials and current role, one or two specific areas of focus or expertise, and something that signals why you on this topic. Keep it tight. The goal is orientation, not a full introduction.

• Your long bio is typically one to two paragraphs and lives in speaker kits, proposal submissions, and anywhere someone needs a fuller picture before deciding whether to book you. It has room for more context: your clinical background, populations you work with, any relevant writing, speaking history, training roles, or professional affiliations. It can have a slightly warmer register than a CV—this is where a bit of your voice can come through. But it’s still a professional document. Lead with what’s most relevant to a booking decision.

A few things worth including across both versions, depending on length: your licensure and any relevant certifications, your practice or institutional affiliation, specific clinical areas or frameworks you work within, notable speaking or training history, and a line about who you typically serve or what you believe about the work. That last one is often what makes a bio memorable rather than just informative.

Write both now, while you’re not under pressure. Save them somewhere you can find in under a minute. Update them when something significant changes. You will use them more than you think.

A simple speaker kit goes further than a long email.

What you need is something you can send when someone asks who you are and what you talk about—a one-page PDF or a simple webpage that does the work of a long email without requiring one. Include your bio, two or three talk titles with brief descriptions, a note about who each talk is designed for, any prior speaking you’ve done, a photo, and contact information. That’s it. Past experience—even modest experience—signals credibility. A conference presentation, a guest lecture, a panel appearance: include it. People are looking for confirmation that you’ve stood in front of a room before, not a TED résumé.

Each talk should have a clear throughline, a few frameworks translated into accessible language, grounding in your own clinical experience, and something the audience can leave with. People pay for practical takeaways. They remember the moment when something clicked. Build toward that.

Where to look for opportunities—especially early on.

The best places to start are the ones where you already have proximity. Professional organizations you’re already a part of. Universities with counseling programs or graduate students who need exposure to practicing clinicians. Nonprofits serving communities you know well. Group practices. Hospital behavioral health departments. Local conferences before national ones.

You already have more of an ecosystem than you might realize. Relationships with colleagues, institutional connections, professional networks you’ve been building for years—these are your first tier. Not because they’re lesser opportunities, but because warm introductions and existing credibility make everything easier.

You’re not starting from zero. You’re starting from where you already are.

On pitching: you are offering value, not asking permission.

Keep it relational and specific. A short email that explains who you are in a sentence or two, names something particular about why you’re reaching out to this organization or event, and offers one or two talk ideas relevant to their audience will always outperform a general inquiry.

A rough template to work from:

Hi [Name], I’m a [your role] based in [location], and I do a lot of work around [your lane]. I’ve been thinking about your [team/students/community], especially given [something specific about them], and I’d love to offer a talk that supports [their need]. A couple of topics that might be relevant: [Talk title one] and [Talk title two]. Happy to share more or tailor something specific.

You are not asking for a favor. You are offering something that could serve their audience. Hold that distinction—it changes the energy of the message.

Questions I ask before I accept a speaking engagement.

Before I commit to anything, there are a few things I want to know. Getting comfortable asking these questions is part of treating your time as a professional resource.

• Who is the audience, and what do they already know? A talk for a general community audience and a talk for licensed clinicians require entirely different calibration. Assumed knowledge matters. Developmental level within the audience matters.

• What is the event’s theme or focus, and where does my piece fit? I want to understand what’s happening before and after me, what the organizing committee is trying to accomplish, and how my contribution supports that.

• What are the logistics? Length, format, whether there’s a Q&A, whether I need to submit materials in advance, whether there’s an honorarium or travel coverage. These aren’t awkward questions. They’re professional ones.

• What is the audience expecting to leave with? A takeaway-driven audience wants practical tools. A reflective audience wants framework and language. Knowing the expectation helps you meet it.
  
  (Not an exhaustive list, but I hope it helps you think before saying yes!)

Subscribe now

On compensation: a rough orientation.

I want to be honest about how this actually progressed for me, because I think the sanitized version of this conversation doesn’t help anyone.

I volunteered my time first. For a while, that made sense—I was building experience, establishing credibility, getting comfortable in rooms I hadn’t been in before. Then sometimes a small stipend or honorarium was offered without my asking. Sometimes travel or lodging was covered. And then there were times when nothing was offered, and I had to ask—and it was uncomfortable. It still is, if I’m being truthful. Knowing your worth in the abstract and actually naming a number out loud in a negotiation are two very different things, and I haven’t fully perfected the latter.

What I have had, though, is the gift of watching other women in my life do it well. Women I admire deeply—who move through those conversations with a kind of grounded certainty that says: my time and expertise have value, and free labor is not on the table. I’ve tried to emulate that. I’m still learning it. But having it modeled for me made it possible to practice, even when it felt uncomfortable, even when I stumbled through it.

I share that because I think a lot of us—particularly those of us who were socialized to be accommodating, to be grateful just to be in the room—carry a particular weight when it comes to these conversations. The discomfort is real. It doesn’t mean you’re doing it wrong.

And it wasn’t just the money conversations that required that kind of nerve. Sometimes I had to let people know I was interested in the first place—that I wanted to be considered, that I was available, that I had something to offer. That felt like self-promotion in the most uncomfortable sense of the word. Shooting your shot, sitting with the silence after, tolerating the possibility of rejection. We ask our clients to do this all the time—to take risks, to advocate for themselves, to move toward discomfort in the service of something they want. Stepping into that same bravery myself is something I am still actively learning. I don’t think it fully goes away. But I’ve come to believe that getting more practiced at not letting rejection stop you is part of the work—for us just as much as it is for the people we sit with.

As a rough orientation on numbers: smaller organizations and nonprofits tend to fall in the range of a few hundred to around fifteen hundred dollars. Universities, hospital systems, and mid-size conferences often go higher. Corporate and workplace speaking—especially DEI-focused engagements—commands significantly more.

I’m sure others calculate this differently, but here’s how I think about it: I add up my preparation time, travel, any back-and-forth communications with the planning committee, and the length of the engagement itself—then I hold that total up against my standard out-of-network hourly rate. That gives me a baseline before I enter any conversation about compensation. It doesn’t always determine what I charge, but it keeps me honest about what I’m actually exchanging—and it means I’m making a conscious choice rather than just accepting whatever number gets offered. When you don’t have full visibility into a budget yet, it’s not unreasonable to say: “I’m happy to discuss options depending on scope.”

The goal isn’t to price yourself out of opportunities. The goal is to not chronically underprice yourself because the conversation feels uncomfortable.

Before you walk in: two things most people don’t prepare.

The first is a short list of people who can speak to your work—colleagues, supervisors, or past clients who know what you bring to a room and would be willing to say so. After a talk goes well, someone in the audience may want to know more before they book you. Having a name or two you can point them toward—with permission—carries more weight than anything on your speaker bio.

If you’ve worked with someone who experienced your clinical work or your training and you have a genuine relationship, a gentle ask for an endorsement is appropriate. Most people are glad to be asked. What makes it land well is asking specifically—not “would you say something nice about me” but “would you be willing to share a sentence or two about your experience working with me, specifically around X?” The specificity makes it easier for them and more useful for you.

The second thing to prepare is a way for people to reach you. This sounds obvious, and yet. I have been genuinely surprised—more than once—by who was sitting in the audience. A potential collaborator. Someone building a program who needed exactly the perspective I’d just shared. A journalist working on a piece.

You cannot predict who shows up, which means you have to be ready for it when they do.

I want to be specific about this because I think it’s undersold: some of my most meaningful speaking opportunities didn’t come from pitching myself or submitting proposals. They came from someone sitting in the audience at a conference or training who approached me afterward and asked if I was available for something else entirely—a different event, a different organization, a different context I hadn’t been thinking about at all. That has happened more than once, and it’s shaped how I think about every room I walk into. You are not just there to deliver a talk. You are there to be known. And the people who come to know you in one room are often the ones who open the next door.

A business card still works. A QR code to your website or newsletter works. A verbal mention of where people can find you before you close works. Whatever it is—have it ready, and say it out loud. Don’t wait for people to find you afterward. They won’t always. But if you make it easy, some of them will.

Share

One talk, many doors.

Before we talk about what a single talk can become, let’s talk about the follow-up—because this is where a lot of people drop the thread.

After an engagement, send a thank you. A note, an email, something that acknowledges the people who invited you in. And if it’s within your means, a small gesture—a card, something simple—goes a long way. This isn’t transactional. It’s a matter of respect and community. When someone invites you to speak, they are bringing you into a space with their colleagues, their students, their people—people they have relationships with and feel some responsibility toward. That’s not a small thing. Honoring it, even briefly, signals that you understand the weight of the invitation and that you don’t take it for granted. In my experience, that kind of follow-through is remembered. It’s also just the right thing to do.

From there: a single talk—well-developed and well-received—can become a paid workshop, a CE training, a recorded course, a keynote, a Substack essay, or the foundation of a consulting offering. The content you develop for one context rarely has to live only there. Ask for a testimonial. Ask for a referral. Ask who else you should be talking to. One room consistently opens into the next—but you have to be willing to ask.

What will actually make you good at this.

Being booked and being in demand are different things. What closes that gap has less to do with your credentials and more to do with how you show up.

Your voice is your differentiator. The ability to name what people have felt but couldn’t articulate—to take clinical insight and translate it into language that lands—is not as common as you’d think. That’s not lecturing. That’s creating a moment of recognition, which is what people remember long after the content fades.

The best speakers feel like: this person gets me. Not: this person is impressive. The distinction matters more than most of us were taught to believe.

And stay clinically grounded. It’s your edge. You’re not a motivational speaker and you’re not just an educator. You’re someone with training, direct clinical experience, and a framework for understanding why people struggle and what they need.

That combination is rarer than the forum comment suggests.

Before you close this tab: a starting sequence.

Work through this in order, not all at once.

1. Clarify your lane. Answer this in writing—not a topic, a perspective: if someone hears me speak once, what do I want them to understand differently? If you’re struggling to see yourself in that space, ask someone who knows your work. A trusted colleague, a friend who has collaborated with you or even watched you work behind the scenes—their perception of what you bring may illuminate something you’ve been too close to see yourself. Sometimes others hold the image of us we haven’t yet claimed.

2. Start with an online presence if going out feels like too much. A newsletter, a blog, consistent posts about what you’re thinking about clinically. No stage required. No deadline. If someone reads it, great—but that’s not the point. The point is that your perspective is now findable.

3. Draft one talk. A working title and two to three sentences—what it covers, who it’s for, what someone leaves with. You’re not committing to anything. You’re giving yourself something concrete to work from.

4. Write your bios. Both versions, before you need them. If you skipped that section earlier, go back. Keep them somewhere you can find in under a minute.

5. Build your speaker kit. One page. Bio, talk descriptions, who they’re for, past experience, photo, contact. Done.

6. Identify three places to start. Look at the ecosystem you already have and pick three places where a warm introduction or existing relationship already exists. Those are your first outreach targets.

7. Take one action this week. Submit a proposal. Send one email. Ask a colleague about co-presenting. One thing. The momentum comes from doing, not from planning to do.

8. Know your number. Add up your prep time, travel, communications, and the length of the engagement, and hold it against your out-of-network hourly rate. Know what you’re willing to accept and why—before you’re in the conversation.

9. Prepare your social proof. Identify two or three people who could speak to your work and reach out when the time is right. Start collecting testimonials after every engagement, however small.

10. Have a way for people to reach you. Before every talk, decide what you’ll say out loud at the close. Say it every time.

11. Follow up. After every engagement, send a thank you. If a small gesture is within your means, send that too. Then ask: for a testimonial, for a referral, for a name. The relationship doesn’t end when you leave the room.

And a few questions worth sitting with as you move through this:

• What do I want speaking to do for my practice or career—visibility, income, relationships, something else? The answer shapes which opportunities are worth taking and which ones to pass on.

• What am I willing to do for free, and for how long? Strategic generosity is real. Chronic undervaluing is also real. Know the difference before you’re in the room.

• What does rejection mean to me, and how do I want to respond to it? You will not get every opportunity you pursue. Having a framework for that ahead of time makes it easier to keep going.

• Who in my life models this well—the asking, the pricing, the visibility—and what can I learn from watching them? You don’t have to figure this out alone. You probably already know someone doing it in a way that resonates. Pay attention.

Share

Speaking engagements are not a passive income stream—let me be clear about that. They require preparation, often significant preparation, and the payment is frequently not proportional to the work involved. What they can offer is visibility, credibility, and the kind of slow-building reputation that eventually opens other doors. If you approach them strategically and with realistic expectations, they’re worth it.

If you approach them hoping to offset your business expenses by next quarter, you may want to revisit the plan.

But if you’re standing nervously in front of a poster somewhere, answering questions one or two people at a time? Stay there. That’s where it starts.

You will find plenty of those. You’ll find Instagram accounts and Substacks and online courses promising you a full caseload, a six-figure income, and the freedom to work from anywhere—all within your first year of practice. Some of those people are telling the truth about their own experience. Most are selling something.

I’m not trying to talk you out of this work. I love this work. But I am going to tell you some things that your graduate program probably won’t, and I’d rather you hear them now than figure them out the hard way—the way a lot of us did.

A note before we dive in: I write from the world of private practice, and most of what follows lives there. But some of it bleeds into the field more broadly—into community mental health, agency work, nonprofit settings, all of it. Take what applies to where you’re headed and hold the rest loosely.

So. Deep breath. Here we go.

You are entering the healthcare system.

Take a moment to actually sit with that. Think about your own experiences with healthcare. Think about your family’s. Think about the stories you’ve heard from clients before you even had clients—the billing nightmares, the insurance denials, the providers who burned out and left, the people who fell through gaps that weren’t supposed to exist.

That is the system you are walking into. Not as a patient. As a provider. And the system does not treat its providers well either.

This isn’t a reason not to go. It is a reason to go in clear-eyed.

You will feel let down by a field that told you it was different.

You chose this profession, at least in part, because it seemed to value people. Empathy, inclusion, cultural humility—these aren’t fringe concepts in counseling and social work, they’re embedded in the language of the field itself. The ethics codes say it. The training programs say it. And you believed it, reasonably, because the values felt aligned with your own.

And then you start looking for yourself in it.

If you hold intersectional, marginalized identities—if you are a clinician of color, a queer clinician, a clinician with a disability, a clinician whose lived experience sits outside the dominant cultural assumptions baked into most training models—you will likely discover, sooner than you’d like, that the profession’s stated values and its actual infrastructure are not the same thing.

The representation gaps are real. In the literature, in the leadership of professional organizations, in the faculty of graduate programs, in the therapists whose names circulate as authorities in the field. The practical resources—the ones that speak directly to your specific experience of navigating this work, building a practice, managing the particular weight of doing this labor while also carrying identities that the broader culture does not always protect—are harder to find than they should be. Sometimes they barely exist at all.

You entered a profession that speaks the language of inclusion fluently and has not yet done the full work of living it. That gap is real, it is not your imagination, and it is not yours to fix alone.

And yet. You may find yourself fixing it anyway—or at least being asked to. There is a particular exhaustion that comes with being one of the few people in a room who represents a specific identity or community, and having that fact become the most visible thing about you. You get called on to educate. To contextualize. To speak for an entire group of people whose experiences are not monolithic and cannot be summarized in a consultation meeting or a panel discussion. The role of spokesperson is rarely chosen—it tends to get assigned—and the feelings that come with it are genuinely mixed. You may feel a responsibility to show up in that way because the alternative is silence, and silence has its own cost. You may also feel the weight of carrying something that was never supposed to be yours to carry alone.

You may end up creating your own resources because the existing ones don’t serve you. Your own reading lists, your own referral networks, your own consultation spaces with people who get it without needing an explanation first. That labor is real and it is generative and it is also exhausting in a way that people outside of it don’t always see.

Finding your community may require more effort than it should. And building it yourself—which many of us have had to do—is both an act of necessity and, in its own complicated way, an act of love for the people who come after you.

It can feel lonely. It can feel like a profound disappointment from a field that promised something different. And in some ways, it is—it is a microcosm of its time, reflecting back the same structural failures and cultural gaps that exist everywhere else, dressed up in the language of healing.

Name the disappointment when you feel it.

The gap between your degree and your license is larger than anyone tells you.

I can only speak from my experience as a counselor, but I suspect this resonates across disciplines: you cannot do much with a graduate degree alone. You need supervised hours. You need to pass licensure exams. You need to accumulate the kind of clinical experience that qualifies you for independent practice—and that process takes years, often costs money, and frequently pays you very little while it’s happening.

The debt you take on in graduate school does not pause while you complete supervision. The bills don’t wait. And the supervised positions that give you hours often come with low wages, high caseloads, and organizational cultures that have normalized therapist burnout as a cost of doing business.

This is not a character flaw in the people who built those systems. It is a structural problem. But knowing that doesn’t make it easier to live inside of.

You are new here—and that is both harder and more useful than you think.

Maybe you’re coming straight from undergrad into a master’s program. Maybe you’re a career changer, someone who spent years doing something else entirely before deciding this was the work you wanted to do. Maybe you’re somewhere in between. Whatever your path, the same thing is true: these are all first experiences for you. And that matters.

There is a particular bind that comes with being newer to a field that asks you to hold other people’s most difficult material. You know things—genuinely, you do. You bring your life, your instincts, your training, your perspective. None of that disappears because you haven’t been doing this for twenty years. But you also don’t know things yet. And the tricky part is that it isn’t always obvious which is which in the moment.

The clinicians I’ve watched grow the fastest are not the ones who performed confidence they didn’t have. They’re the ones who could hold both at once—who could say, internally, I have something to offer here and I am still learning what I don’t know without one canceling the other out. That’s not a soft skill. That’s a clinical orientation.

Curiosity and humility aren’t the opposites of competence. They are competence, at this stage.

Lean into your questions. Stay in supervision. Don’t perform expertise you haven’t earned yet—but don’t shrink from the knowledge and presence you do bring. The work will teach you. Let it.

You will take things personally. That’s information—but it’s not always the truth.

A client will terminate. Maybe with notice, maybe without. Maybe with a kind email, maybe with silence. And before you can stop yourself, you will have already assigned meaning to it—something I said, something I missed, something I am. The story writes itself fast, and it is rarely generous.

This is where the noise lives. The doubt that asks whether you’re actually good at this. The replay of a session moment—something you said, a pause that went too long, an interpretation that landed wrong—that you will return to at 2am like it holds the answer to a question you haven’t fully formed yet. This is imposter syndrome in its most specific, clinical shape: not just abstract self-doubt, but a client walking out the door and your nervous system deciding that’s evidence.

It is not always evidence. Sometimes a client leaves because they got what they needed. Sometimes because life got in the way. Sometimes because the fit wasn’t right—and that is allowed, and it has nothing to do with your worth as a clinician.

And then there’s the feedback that comes from the people around you—supervisors, peers, consultation groups. Some of it will land well. Some of it will land like a challenge you want to argue with, and some of it will send you inward in ways that shut you down instead of opening you up. You will have reactions. That is also information. The question isn’t whether to feel it—you will—but how to sort through it. What is useful here, and what can I set down? What is this person seeing that I might be avoiding, and what is this just not mine to carry?

You don’t have to absorb every piece of feedback as though it is the complete truth about you. You also don’t get to dismiss all of it because it’s uncomfortable.

The practice is learning to stay in that middle space—neither collapsing nor deflecting—and it takes time, probably more time than you think it will.

This is part of why your own therapy matters. Because you will need somewhere to take all of this that isn’t back into the room with your clients.

You need to sort out your relationship with money.

This is true even if you never want to own a business. Even if your entire plan is to work in community mental health or a nonprofit or a school system, you will still have to navigate compensation that often feels misaligned with the depth of work you’re doing.

And if private practice is anywhere in your future—if the idea of having your own caseload, setting your own hours, building something that’s yours has ever crossed your mind—then this is not optional. You need to understand your own money story. What you believe you’re worth. What you were taught to believe about people who charge for their time. The guilt that can creep in when someone pays you for sitting with their pain.

Those beliefs will shape every financial decision you make in this field, often without you realizing it. Doing the work now is not just good personal development—it is professional preparation.

You also need to sort out your relationship with being seen.

We ask our clients to be vulnerable. We sit with them inside the most uncomfortable corners of their interior lives and we hold the belief that looking at hard things leads somewhere worth going.

How much are you willing to do that for yourself?

I’m not talking about disclosure in session. I’m talking about your own therapy—actual, sustained, ongoing therapy, not the few sessions you completed as a training requirement. I’m talking about reflective practice, writing, supervision that challenges you rather than just logging your hours. The therapists who do the most nuanced work are usually the ones who have spent the most time with their own material.

Your self-awareness is not separate from your clinical competence. It is part of it.

The work will get inside you, and you need a plan for that.

You will hear a lot about burnout. It gets mentioned in training programs, referenced in ethics codes, cited in research on clinician wellness. What gets talked about less is how gradual and personal it is—how it doesn’t always announce itself as burnout but instead shows up as irritability, or numbness, or the quiet dread you feel on Sunday nights before a full week of sessions.

This work carries a cumulative weight. Sitting with grief, trauma, crisis, and pain—session after session, week after week—affects you. That is not a weakness. That is a human response to human material, and it has a name: vicarious trauma, secondary traumatic stress, compassion fatigue. These are not things that happen to clinicians who didn’t try hard enough to take care of themselves. They are occupational realities that require active, ongoing attention.

What that attention looks like will be trial and error, and it will probably look different at different points in your career. Some of it is structural—caseload size, scheduling, not booking back-to-back sessions without breaks. But a lot of it is relational. Finding colleagues who understand what this work actually asks of you, who don’t need you to explain why a particular week felt heavy. Building a community of people who respect the boundaries you set, not just tolerate them. Doing your own work on the people-pleasing tendencies that many of us brought into this field—the part that says yes when capacity is gone, that absorbs more than is yours to absorb because saying otherwise feels like failing the client.

Sustainability in this work is not a personality trait. It is a practice. And the earlier you start treating it that way, the better.

This profession runs on unpaid labor, and someone has convinced us that’s okay.

Practicum placements. Pre-licensure supervision. Volunteer hours. The years of early-career work at wages that don’t reflect the training you’ve completed—or the weight of what you’re being asked to carry.

There is a through line in helping professions, human services, care work of all kinds: the idea that doing good is payment enough. That the meaning of the work should offset the material conditions of doing it. That if you’re in it for the money, you’re in it for the wrong reasons.

I want you to notice that idea. I want you to question it. Because it has been used, often, to keep people in roles and systems that take more than they give—and to make those people feel like the problem is their own values, not the structure itself.

Private practice is a service business, and no one teaches you that.

If you want to run a private practice, you are not just a clinician. You are a business owner. You will need to know how to attract clients, how to communicate your value, how to manage your money, how to think about growth and sustainability. You will need marketing skills—and not in a gross way, but in a functional way. People need to find you.

And then there’s this: therapy is a relationship that works toward its own ending. When it goes well, clients leave. That’s the goal. Which means you will always need more clients. The churn is built into the model, and no one walks you through what to do with that—practically or emotionally.

Share

The money part is harder than you expect, and more variable than anyone wants to admit.

This is one of the things I hear most often from newer clinicians who have recently stepped into private practice: the shock of realizing how directly your income is tied to how many clients walk through your door. There is no salary floor here. There is no guaranteed caseload. If you have five clients one week and two the next, you feel that—in your bank account and, if you’re not careful, in your sense of yourself.

Building a private practice from the ground up takes longer than the success stories suggest. It often requires financial support from somewhere else while you’re doing it—another job, a partner’s income, family help, savings. That’s not a failure condition. That’s just what it actually looks like in the early stages for most people.

The version where you open a practice and it fills up immediately exists, but it is not the norm—and treating it as the norm sets people up for a particular kind of shame when their experience looks different.

Know what you’re building toward. Know what it costs you to get there. And give yourself the honest accounting of what you have available to bridge that gap—without pretending the gap isn’t there.

The systems are not designed to be navigable, and that is not your fault.

Getting credentialed with insurance panels. Submitting your licensure application. Understanding what your licensing board actually requires and where to find that information. Figuring out who to call when the answer you received last week contradicts the answer you’re receiving now.

None of this is intuitive. Very little of it is clearly documented. And the people responsible for answering your questions are often overextended, inconsistent, or working inside systems that are themselves fragmented. You will spend time on hold. You will get conflicting information. You will complete a process you thought was finished only to discover there was a step you didn’t know about.

This is not a reflection of your competence. It is a reflection of systems that were not built with providers in mind—and certainly not with newer providers in mind.

Find colleagues who have been through it. Ask the specific questions in consultation spaces. Document everything. And try—genuinely try—not to take the bureaucratic chaos personally, even when it costs you time or money you didn’t have to spare.

No one told you that you’d have to market yourself, and you’re not sure how to feel about that.

You didn’t go into this field to build a personal brand. You went into it because you wanted to do meaningful work with people who needed it. And somewhere between graduation and private practice, you learned that wanting to help is not the same as being findable.

There is a lot of noise out there. A lot of therapist content that feels performative, oversimplified, or optimized for engagement in ways that don’t sit right with you. And you know, probably better than most, how much slop gets mistaken for substance online. You don’t want to add to that. But you also can’t reach clients who don’t know you exist.

The goal is not to be the loudest. It is to be clear—to give people enough of a genuine sense of who you are and how you work that the right ones can recognize themselves in what you’ve written.

That’s not self-promotion in the way you might have feared it. It’s more like—making yourself legible. Saying, in your own voice, this is what I offer and who I’m here for. That takes practice, and it probably feels uncomfortable before it feels natural. But it is part of the job.

Subscribe now

“Just find your niche” is more complicated than it sounds—especially when you’re starting out.

You will hear this advice constantly: niche down, don’t be a generalist, specialize so clients know exactly what you offer. And in theory, that makes sense. A niche is a focused area of clinical specialty—a particular population, presenting concern, or therapeutic approach that you develop deep expertise in over time. Anxiety in adolescents. Grief work with older adults. Trauma-informed care for first responders. The idea is that specificity makes you more findable and more credible to the clients you’re best suited to serve.

But here’s what that advice glosses over for clinicians who are newer to the field: you may not have a niche yet, and that is okay.

What you likely have is exposure. An internship placement, a volunteer role, a practicum site—places that introduced you to specific populations because that’s where the training opportunity happened to be. And there’s real value in that experience. It is genuinely yours. But exposure is not the same as specialization, and calling it a niche before you’ve had the time and volume of clinical experience to actually develop depth there is a different thing entirely.

Give yourself permission to be broader early on. To see what kinds of clients and presenting concerns genuinely draw your attention and energy. To notice what lights you up clinically and what depletes you. That information will point you toward a niche more honestly than any branding exercise will.

The specialization will come. You don’t have to declare it before you’ve earned it.

Many therapists do more than one thing. You’ll have to decide if that’s for you.

As you enter the field, you’ll start to notice that a lot of clinicians are not doing clinical work exclusively.

Some offer supervision or consultation once they’re licensed to do so. Some speak at conferences or trainings. Some create digital products—courses, guides, templates. Some write. Some maintain another job entirely alongside their practice, either because they want to or because the income variability of private practice makes it necessary.

There is no single right answer here. For some people, multiple streams of work bring energy and financial stability. For others, the overhead of running a practice is already enough—adding more roles or revenue lines creates fragmentation that isn’t worth it. This is a deeply personal calculation, and it involves honest questions: Do you have the time and capacity for this right now? Do you have the resources—financial, relational, logistical—to build something additional without it coming at the expense of your clinical work or your own wellbeing? Are you drawn to this because it genuinely excites you, or because the financial unpredictability of practice feels scary and this feels like control?

What I’d caution against is deciding before you have enough information. Give yourself time to understand what running a practice actually asks of you before you layer more onto it.

And if you do eventually add other work—supervision, content, speaking, whatever it is—make sure it’s a choice you’re making, not a reaction to pressure you haven’t fully examined yet.

There is a real bind if you want to serve specific communities.

If your clinical aspirations are tied to reaching particular populations—communities that have historically been underserved, people with fewer resources, the clients who need care the most and can access it the least—you may find yourself navigating a genuine tension between your values and your finances.

Meeting people where they are often means sliding scale fees. It sometimes means community mental health settings with limited pay and significant administrative weight. It can mean choosing between the work you believe in and the income that makes your own life sustainable.

I don’t have a clean answer to that. I just want you to know it’s a real tension, not a personal failure—and it’s worth thinking about before you’re in the middle of it.

Do not compare your practice to what you see online.

People will sell you frameworks, templates, and masterclasses on building an out-of-network private practice. Some of that content is genuinely valuable. Listen to as much of it as you can. But understand what you’re not always seeing: the circumstances that made the path possible.

I’ll say it plainly about myself. I lived at home, rent-free, for a significant portion of my training. I have a partner whose income and benefits provided stability I could not have created alone. I had access to resources, networks, and community support that are not universally available. My path was not only a product of my effort. Effort was part of it. But it was not the whole story.

No one can guarantee you their results. Be skeptical of anyone who implies otherwise.

And there are so many skills they didn’t teach you.

How to talk to potential clients about money. How to write a Psychology Today profile that sounds like you. How to set a fee that reflects your worth without sending you into a spiral. How to handle the slow months without catastrophizing. How to build a referral network. How to take a real vacation.

These things matter. They are not less important than your clinical skills. They are the infrastructure that lets you keep doing the clinical work at all.

I told you I was going to be a bummer. I meant it.

And I also want to say this: it is not glamorous. It has never been glamorous. But it is the most meaningful thing I have dedicated my life to—and I don’t say that lightly or as a consolation prize for everything I’ve just described. I say it because it’s true, and because I think you deserve to hear both things at once.

What I have to say about this profession changes. That’s a good thing. The field is not static, and neither am I, and I hope that some of what I’ve written here eventually becomes outdated.

I hope that asking for help and receiving mental health services becomes less stigmatized. I hope insurance providers pay clinicians what the work is actually worth. I hope the rise of venture-backed platforms stops feeling like a threat to independent practitioners trying to do this work with integrity. I hope the next generation of therapists has better coursework, better financial preparation, better structural support than most of us had.

I hope I’m wrong about some of this. I genuinely do.

But until then—go in knowing. Ask the hard questions early. Find your people. Do your own work. And trust that the profession needs exactly what you have to bring to it, even on the days when that’s hard to believe.

People-pleasing is practically a prerequisite for becoming a therapist. The empathy, the attunement, the deep discomfort with conflict—these are the same qualities that make someone good in a session and quietly exhausted outside of it. The field selects for a particular kind of person, and that person, more often than not, has some version of the same wound: a finely tuned radar for other people’s discomfort, and a long history of making themselves smaller to manage it.

That’s not a criticism. It’s an observation. But it’s one worth sitting with—because if you recognize yourself in it, this isn’t just a professional development note. It’s a personal one.

There’s a joke that circulates among therapists—that our own trauma chose this profession. (I am looking at you, Jung! ::cough:: wounded healer archetype::)

That our capacity to sit with pain, to hold space for the unbearable, to stay steady in the middle of someone else’s crisis didn’t come from nowhere. Most of us laugh when we hear it, because it’s true enough to be funny and a little too true to be entirely comfortable.

And it’s worth staying with that discomfort for a moment, because underneath the joke is something that matters clinically.

The same histories that shaped our strengths can also shape our blind spots. The parts of us that learned early to attune, to accommodate, to make ourselves smaller in service of keeping the peace—those parts don’t automatically get resolved when we enter the field. They come with us. And when they’re unexamined, they can quietly work against the very people we’re trying to help. Not out of carelessness. Not out of bad intent. But because we haven’t yet found our way to working with that part of ourselves.

This isn’t about blame—it’s about honesty. The most useful thing we can do with that recognition is get curious about it, ideally with support, and ask where it might be showing up.

Subscribe now

Here’s where it shows up in practice, and I want to be specific, because the generic version of this conversation lets us off too easy.

• It shows up when a client asks to squeeze in one more session and you say yes—even though you’re already past the point where your mind and body can show up effectively. You tell yourself it’s because you care. And you do care. But underneath that is something quieter: the fear that saying no means losing them, disappointing them, confirming that you’re not as dedicated as a good therapist should be.

• It shows up when the conversation about your fee turns into you offering a reduction you can’t actually sustain. The healthcare system is genuinely broken, and your conscience about that is real and valid. But at some point, absorbing that brokenness into your own financial instability isn’t advocacy—it’s self-erasure dressed up as compassion.

• It shows up at the end of session, when the conversation is clearly not finished and you can’t bring yourself to interrupt it. Ending feels rude. Containing feels cold. So you let it run, and you tell yourself the client needed those extra minutes—when really, your supervisor has probably already named what’s actually happening: that you’re struggling to hold the boundary not because it wouldn’t serve the client, but because tolerating their discomfort in that moment is something you haven’t yet learned to sit with.

• It shows up when a client cancels last minute or misses a session entirely, and you waive the fee—again. Not because the circumstances warranted it, but because the thought of charging them feels confrontational. Because you’ve already written the awkward exchange in your head and decided you can’t handle it. Because some part of you believes that enforcing the policy you set will cost you the relationship entirely.

So you absorb it. You tell yourself it’s a one-time grace, and then it happens again, and you absorb that too. And quietly, underneath the repeated accommodation, something begins to shift—not just in your bank account, but in the dynamic. The boundary you established at the start of treatment has become a suggestion. The client may not even realize it, but they’ve learned that your policies are negotiable, that your limits are soft, that your discomfort with conflict will reliably work in their favor.

What’s also getting lost in that pattern is something genuinely clinical. Late cancellation conversations, handled well, are an opportunity—to revisit the frame, to explore what’s happening for the client around showing up, to model what it looks like to hold a professional expectation with warmth and without apology. When we waive our way around those conversations, we’re not protecting the relationship. We’re preventing something real from happening in it.

Avoiding the difficult conversation doesn’t preserve the therapeutic relationship. It quietly teaches the client that you don’t trust yourself—or them—enough to have it.

And if a pattern of cancellations or boundary violations has become persistent, that’s not just an administrative inconvenience. It may be a clinical signal worth exploring—one that deserves a direct, boundaried, and compassionate conversation about whether the current structure of treatment is still working. That conversation is part of your professional role. Waiving the fee to avoid having it isn’t kindness. It’s a way of opting out of the very thing you’re there to do.

The accommodation reflex isn’t about generosity. It’s about what you’re afraid will happen if you stop accommodating.

Share

That fear usually sounds something like: if I’m not endlessly available, I will lose this person. If I enforce a limit, they will leave. If I say no, I will have failed.

But I want to name something underneath even that. Because for many of us, the people-pleasing isn’t only about the client relationship—it’s about a much older and more personal discomfort with taking up space. With being visible. With having needs that are allowed to exist in the same room as someone else’s pain.

But when that doubt feels familiar—when it shows up across clients, across contexts, across years—it may be pointing to something larger than professional development. It may be pointing to wounds that haven’t yet had the attention they deserve.

The question isn’t whether you have these tender places. Most of us do. The question is whether they’re running the session without your awareness.

And there’s a specific shape this can take that’s worth naming directly. When the responsibility we feel toward clients goes unexamined, it can stop feeling like professional commitment and start feeling like something older—something more intimate and more loaded. It can begin to mirror what clinicians trained in family systems work might recognize as a parentified dynamic.

Parentification happens when a child learns, early and often, that it is their job to manage the emotional world of the adults around them. To anticipate needs, absorb distress, keep the peace. Their sense of worth becomes inseparable from how well they perform that role. They don’t just care about the people they love—they feel responsible for them. For their moods, their stability, their outcomes.

That pattern, carried into the therapy room, can quietly reshape the clinical relationship. The client’s lack of progress starts to feel like your failure. Their pain starts to feel like your responsibility to fix. Their dissatisfaction—real or imagined—starts to feel like an indictment. And so you work harder, stay longer, charge less, bend further. Not because the clinical picture calls for it, but because somewhere underneath the professional reasoning is a much older belief: that if someone in your care is struggling, it is because you have not done enough.

Feeling responsible for a client’s growth is part of the work. Feeling responsible for their change is a sign that something personal may have entered the room.

People-pleasing and perfectionism are first cousins. They don’t always look the same, but they share a root: the fear that who you are and what you do will not be enough—and that the consequences of that will be relational. Someone will leave. Someone will be disappointed. Someone will finally see what you’ve been quietly afraid they’d see all along.

In this field, that fear often disguises itself as conscientiousness. As high standards. As dedication to the craft. And to be clear—rigor matters in this work. Wanting to get it right matters. But there is a meaningful difference between clinical thoughtfulness and the white-knuckled terror of making a mistake.

That terror has real and tangible consequences in the room.

It shows up when a client shares something raw and unexpected and instead of staying present, your mind races to find the right response—the perfectly attuned, clinically sound, theoretically grounded response—and in chasing it, you miss the moment entirely. The client needed you to be with them. You were busy trying to be impressive.

It shows up when you avoid introducing a difficult observation or a gentle confrontation because you’re not certain you’ll deliver it well enough. So you stay in safer territory, and the session stays comfortable, and nothing particularly challenging gets said—and the client leaves the same way they came in, week after week, because you couldn’t tolerate the risk of getting it slightly wrong.

It shows up in supervision, too. When you present only the sessions that went well, or frame your uncertainty as a clinical question rather than a personal one, because admitting that you froze, or misread something, or said the wrong thing feels like too much exposure. Perfectionism in supervision is particularly costly—because supervision is precisely where mistakes are supposed to live. It’s where they become learning. When we can’t bring our actual stumbles into that space, we rob ourselves of the development those stumbles were trying to offer.

Perfectionism doesn’t protect your clients from your mistakes. It protects you from having to know about them.

And perhaps most subtly, it shows up in the therapeutic relationship itself. Clients are exquisitely sensitive to inauthenticity, even when they can’t name it. When a therapist is performing competence rather than practicing it—when they’re managing their own anxiety about being enough rather than genuinely tracking the client in front of them—the relationship becomes slightly hollow. There’s warmth, there’s professionalism, but there’s a layer of glass between you. The client may not know why the connection feels slightly off. But they feel it.

Authentic therapeutic relationship—the kind that actually heals—requires a therapist who can be uncertain, who can name a wrong turn, who can say I don’t think I understood what you were telling me last week, can we go back? That kind of repair is not a sign of failure. Research tells us consistently that it’s one of the most powerful things that can happen in a clinical relationship. But you can only do it if you’re not more committed to appearing flawless than to being real.

The willingness to be imperfect in front of your client is not a liability. It’s one of the most therapeutic things you can offer them.

Share

When we haven’t done the work of learning to occupy space in our own lives, we can’t fully model it for the people sitting across from us.

This is where it gets clinical. Because the accommodation reflex isn’t just a personal pattern—it becomes a parallel process. Clients who also struggle to take up space, to ask for what they need, to trust that their presence is welcome without constant appeasement—they are watching us. They are learning from how we hold ourselves, not just what we say. If we can’t end a session, charge our fee, or decline a request without unraveling, we’re not modeling the thing we’re trying to help them build.

And because the stakes feel so high—we’re talking about people’s mental health, their trust, their willingness to keep showing up—the guilt mechanism kicks in hard. It can masquerade as clinical reasoning. It can sound like ethics. It can feel indistinguishable from genuine care.

But guilt and care are not the same thing, even when they arrive together.

One of the harder truths about this work is that the most therapeutic thing you can offer a client is not your limitless availability. It’s your honest, boundaried, sustainable presence.

When you say yes past your capacity, you’re not giving the client your best—you’re giving them what’s left. When you reduce your fee below what you can afford, you’re not modeling financial wellness—you’re modeling self-abandonment. When you can’t end a session, you’re not being compassionate—you’re avoiding the discomfort of being the one who holds the frame.

The client doesn’t need you to be endlessly accommodating. They need you to be real.

Share

If you find yourself in any of this, bring it to supervision. Not as a confession, and not because something is wrong with you—but because this is exactly the kind of material supervision exists to hold.

If you’re not sure where to start, here are a few ways in:

• I’ve been noticing that I have a hard time saying no to clients, even when I know I should. I want to explore what’s underneath that.

• I’ve been going over time in sessions and I’m not sure if it’s clinical judgment or something else. Can we look at that together?

• I think I might be tying my sense of worth as a therapist to how available I am. I’d like to understand that better.

• I notice I get anxious about saying the wrong thing in session. I want to explore whether that’s getting in the way.

• I’ve been waiving my cancellation fee more than I should, and I think it might be about more than just being flexible. Can we look at that?

You don’t need to have it fully figured out before you bring it to your supervisor. That’s what supervision is for—not to present a polished insight, but to think out loud in a space that can hold it.

The people-pleasing didn’t develop overnight, and it won’t unwind overnight either. But noticing it—really noticing it, without immediately justifying it as clinical intuition—is the beginning. So is the slower, more uncomfortable work of learning to take up space in your own life: to have a limit that holds, a fee that reflects your worth, a body that gets to leave the office on time. And if what surfaces in that process feels bigger than professional development—if it feels old, and familiar, and heavy in a way that exceeds the work context—that’s worth tending to. In your own right. Not just as a clinician, but as a person.

You’re allowed to say no. You’re allowed to end the session. You’re allowed to charge what you charge.

And your clients, more than your endless accommodation, need to see you do exactly that.

A (wonderful) client of mine yawns at the beginning of session, hand flying up to cover their mouth, and before I can say anything, the apology is already out: “I’m so sorry, I promise I’m not bored.” Sometimes it’s tiredness they’re disclaiming. Sometimes it’s disengagement. But there’s always the apology, and there’s always the same slightly embarrassed look—like the body did something it wasn’t supposed to.

The moment that’s stayed with me most, though, went a little differently.

A client yawned, she paused and said something like—”I don’t even know why yawning means you’re bored. Where did that even come from?”

We both laughed. I yawned shortly after from that contagious effect yawning seems to have. And then I paused, because honestly? I didn’t know either!

“I have no idea,” I told her. She gave me lots to think about!

It was a brief exchange. Maybe thirty seconds. But it’s one I keep returning to, because it cracked something open.

Here’s what I find myself returning to: yawning isn’t really about boredom. That’s the story we’ve absorbed—from classrooms, from polite company, from years of being shushed or side-eyed for doing it at the wrong moment. But physiologically, a yawn is something closer to a reset.

It’s your nervous system recalibrating itself in real time.

Yawning is tied to the autonomic nervous system—that internal regulator that’s constantly managing the balance between activation and rest. A yawn can nudge an overstimulated system toward calm, or wake up a system that’s gotten too still. It involves a deep breath, a stretch of the jaw, an activation of the vagus nerve. That’s the nerve central to our parasympathetic response—the one that slows the heart rate, supports a sense of grounding, helps the body shift from bracing to settling.

In somatic and trauma-informed frameworks, a yawn in session is often considered a good sign. It can mean the nervous system is discharging activation, that something is loosening, that the body is moving toward felt safety. Clinicians who work somatically are sometimes taught to notice—even welcome—a yawn as evidence that something is shifting.

There’s also the contagion piece, which I find quietly remarkable. We’re more likely to “catch” a yawn from someone we feel connected to. It’s linked to mirror neurons, to empathy, to attunement. In that way, two people yawning in close succession isn’t awkward—it might actually be co-regulation made visible.

To be clear: I’m not dismissing sleep here. Sleep hygiene is a genuinely important determinant of health, and if someone is exhausted, that matters clinically and deserves attention. But a yawn doesn’t only mean exhaustion—and that distinction is worth sitting with. We’ve collapsed a complex signal into a single, somewhat unflattering story. And I think it’s worth asking where that story came from, because it isn’t universal. The shame around yawning—the sense that the body has done something impolite or revealing—is deeply social and learned. Some of it is cultural. Which means it can also be unlearned.

Part of this work is expanding our ideas of what our bodies are actually communicating—and giving ourselves, and our clients, more room to interpret those signals with curiosity rather than embarrassment.

Share

And yet we hide them.

I’ll admit it: I’ve done this too. There’s an implicit training that happens in this field—not always stated outright, but absorbed—that therapists should suppress yawns in session. The rationale makes sense on the surface. We don’t want a client to feel like a burden, like they’re losing us, like the work isn’t worth our full attention.

But there’s a cost to that suppression that I think we underexamine. When we override a natural physiological signal in the name of appearing regulated, we’re not actually regulating—we’re performing it. And that performance, repeated across sessions, across years, is part of what quietly hollows therapists out. It’s one small piece of a much larger pattern of emotional labor that can erode authenticity over time if we’re not paying attention.

There’s a difference between being present and performing presence. Sometimes the body knows something before the mind has caught up.

I’m still working on my own reflexive impulse to apologize for a yawn—that social conditioning runs deep, and I won’t pretend I’ve fully shed it. But what I’ve tried to do instead is own it. When a yawn comes, I let it become what it actually is: a deep breath, sometimes accompanied by a stretch if the moment allows. I don’t hide it from the client. If anything, I want them to witness it—because modeling security in your own body, and awareness of what it’s doing, is part of what we’re trying to cultivate together in the room.

The moments I’m describing—clients pausing in session to question an assumption their body just surfaced—those are actually invitations. Invitations to be honest about what we don’t know, to sit in the not-knowing together, to model the kind of curious, non-judgmental relationship with the body that we’re often trying to help clients build for themselves. When I said “I have no idea” and meant it, something in the room relaxed. That wasn’t a therapeutic technique. It was just the truth.

What I’ve come to understand is that when a client yawns in session, it often tells me something useful. Not that they’re bored or checked out, but that something in them has relaxed enough to let their system do what it needs to do. That’s not nothing. In fact, that’s a lot.

Honestly? These days, when a client yawns, I take it as a compliment. It tells me the room feels safe enough for their body to stop bracing. That’s exactly what we’re working toward.

I don’t know that I have a clean takeaway here. This isn’t the kind of piece that ends with three things to try this week. It’s more of an invitation to notice—the ways our bodies communicate without asking permission, the stories we’ve inherited about what those communications mean, and the moments in session when the most therapeutic thing might be to let what’s true be true.

That question—I don’t know why yawning means you’re bored—has stayed with me. Such a small observation. But it lingered, because it was right, and because neither of us had ever really questioned it before.

Sometimes the work isn’t in the words. Sometimes it’s in what the body already knows, and what happens when we finally stop apologizing for it.

This is one of those areas where training programs tend to stay quiet, ethical codes leave room for interpretation, and practitioners end up cobbling together a practice from whatever they absorbed in graduate school and whatever their supervisors happened to model.

So let me share what I actually told her—and why I think about it the way I do.

First, let’s define what we’re actually talking about

When she says informal peer consultation, she means the kind of thing most of us do regularly without even giving it a name. You’re stuck on something with a client. You call a colleague. You talk it through. They offer a perspective, ask a clarifying question, suggest something you hadn’t considered. You hang up feeling less alone in it and go back to the work.

That’s different from a formal consultation—when you bring in another clinician who has a documented role in the client’s care, or when there’s a release of information in place and you’re coordinating directly with a psychiatrist, a PCP, or another treating provider.

Both matter. Both have documentation implications. But they’re not the same thing, and conflating them is part of where the confusion starts.

The short answer

You are not required to document informal peer consultations in the client’s chart. And in many cases, it’s actually more appropriate not to.

Informal consultations are part of your clinical thinking process—not a formal part of the client’s medical record.

Here’s how I break it down.

Subscribe now

Charts should reflect what’s necessary and relevant to care

Treatment decisions. Risk. Coordination. Continuity. Those are the things the chart is for. Informal consultations don’t automatically rise to that level—unless they actually lead to a clear clinical decision or a meaningful change in how you’re working with someone.

Ask yourself: did this conversation produce something that will affect the client’s care? If yes, you can document the outcome of that thinking in the chart. If no—if it was more about processing your own reaction, getting a sanity check, or thinking out loud—that’s internal to your clinical process, and it doesn’t necessarily belong in a legal document.

Confidentiality and the minimum necessary standard

Even when we’re being thoughtful about de-identifying—even when we’re careful to change details or speak in general terms—informal consultations can still involve more identifying information than you want embedded in a formal medical record.

Keeping those notes in a separate, secure place is actually very consistent with minimum necessary principles. You’re not trying to hide anything. You’re being intentional about what goes into the legal record and why.

Discoverability is real and worth thinking about

Anything in the chart is part of the legal record. It can be subpoenaed. That doesn’t mean you should scrub your documentation out of fear—clear, thorough records are generally protective. But it does mean you should be intentional.

Adding informal consultation notes to a chart can sometimes introduce complexity rather than clarity, especially if it surfaces another clinician’s opinion from someone who has no formal role in the client’s care and no relationship with what’s in the record.

The goal isn’t to avoid accountability—it’s to document what’s actually yours to document.

So where do informal consult notes actually go?

If you’re going to keep a record of informal consultations—and I think there’s real value in doing so, even if it’s not required—keep them somewhere secure and private. A password-protected document, a dedicated notebook, however you manage your personal clinical records. Limit identifying information. Focus on your own reasoning and what you took away from the conversation, rather than a verbatim account.

The one time I’d consider including something in the chart: if the consultation directly informs a significant clinical decision. Safety planning. A diagnostic shift. A meaningful change in treatment approach. In those cases, you can note it briefly and generally—something like “consulted with colleague regarding treatment considerations; plan updated accordingly”—without naming anyone or reproducing the conversation.

A quick breakdown

Formal consultation—a psychiatrist, care coordinator, or someone with a release in place and a direct role in the client’s care—document it in the chart. Always.

Informal consultation—a colleague serving as a sounding board with no direct involvement—optional. Often better kept in personal notes. If it leads to a concrete clinical decision, you can note the outcome briefly in the chart.

Why there’s no single right answer

Here’s the part that frustrated my colleague (and honestly frustrates me too): boards vary. Malpractice carriers vary. Some will recommend one thing; others will recommend something else entirely. That inconsistency is real, and it’s not going away.

Which means this becomes less about finding the one correct rule and more about building a practice that’s defensible, intentional, and grounded in clinical necessity. The guiding question isn’t “what am I technically required to document?” It’s “what does this client’s care actually require, and what reflects my professional judgment?”

Document what is necessary for the client’s care and continuity—not every part of your internal process.

Your informal consultations are part of how you think. They’re part of how you grow. They don’t all need to live in the legal record. But they do deserve to be taken seriously—which is exactly why it’s worth having a clear, consistent practice around them.

The worry.

Not the kind you shake off. The kind that settles in when you’ve done the work to get here and you’re still not sure when here starts to feel like something. They were asking the right questions, tracking the right things. And still: the silence of a caseload that hasn’t filled yet was starting to feel like personal commentary on their emerging identity as a therapist.

I wanted to tell them—and I want to tell you—that this is not a you problem.

Almost every therapist in private practice has sat where you’re sitting. The ones who look established, whose schedules look full, who post about their niche with apparent confidence—most of them remember this exact feeling. And honestly? I’m not exempt from it either. Even now, after years in practice, when I take time off I feel it—that low hum of will it come back, will the rhythm return? The dips and fluctuations have become harder to predict with any confidence. The economy is shifting underneath all of us, and the old markers don’t hold the way they used to.

There used to be patterns—a summer slump, a holiday dip, a January surge. Clinicians passed this around like gospel, and for a while it kind of held. But jobs are shifting, people are relocating, the news is relentless and so is the financial uncertainty it produces. The rhythms are harder to read, which means the waiting is harder to contextualize.

If you’re new, the silence hits different. It starts to feel like information. Like something is wrong.

It’s not. But knowing that and feeling that are two very different things.

And here’s the part that doesn’t get talked about enough: the waiting is also when our insecurities show up uninvited.

Am I doing enough? Did I miss something? Should I be further along by now?

You had everything to do, and now you’re waiting. That whiplash is real.

It doesn’t mean you’re behind. It means you’re in a season that nobody fully prepared you for—the in-between, where the foundation isn’t visible yet and the caseload isn’t full yet and you’re holding a lot of competence with nowhere to put it.

That’s not failure. That’s the beginning.

Here’s what I told my supervisee, and what I want to offer you: this window—uncomfortable as it is—is actually the most available you are ever going to be. Once your caseload builds, everything I’m about to mention gets pushed to the bottom of the list indefinitely. This isn’t dead time. It’s the only stretch where you get to build the foundation without also trying to hold everything else up at the same time.

So here’s some guidance for what to do with that energy—because it deserves somewhere to go.

Your online presence deserves a real look

Pull up your Psychology Today profile and your website and read them like a stranger would. Not like someone who knows what you do and why it matters—like someone who is exhausted, maybe a little skeptical, and trying to figure out in thirty seconds whether you get it.

Most profiles default to credentials and clinical language. That’s not what a prospective client is scanning for. They’re looking for recognition—does this person understand what I’m going through?

Psychology Today gives you limited characters. Use them well. If you’re choosing between listing a modality and naming a struggle your ideal client actually has, name the struggle. “I work with adults navigating anxiety” tells someone less than “I work with high-achieving adults who can’t turn their brain off at night.”

And yes—we all know Psychology Today is a dated directory. At this point there’s a whole debate in the field about whether it’s even worth the subscription fee, and honestly the answer is mixed. Some clinicians swear by it, others say it does more for their SEO than it ever did for direct referrals. But here’s the frame that’s helped me think about it: your name in the digital space is like real estate. If you ever played Monopoly as a kid, you know the more properties you own, the more leverage you have. It’s the same idea here. The more places your name appears online—with consistent, intentional messaging—the stronger your SEO footprint. Psychology Today, for all its limitations, is a high-authority domain. Being on it means Google associates your name with it. Whether a client finds you through it is almost a secondary question at this point.

So if you can afford it and you’re willing to do it with intention and consistent messaging, it’s probably worth it—not as a referral pipeline, but as a piece of digital land with your name on it.

Ask yourself:

• If someone who had never heard of me read this, would they know within two sentences who I help and how?

• Am I leading with what I do, or with what my client is experiencing?

• Is there anything here that sounds like it belongs in a clinical chart rather than a conversation?

• What would I cut if I had half the space?

Build the welcome experience you’d want

If you don’t have a welcome packet yet, now is the time. Not a legal disclaimer dressed up with a logo—an actual orientation to what working with you looks like.

The clients who feel held from the very first touchpoint are the ones who stay and refer. That packet is part of your clinical frame before the clinical work even starts.

Think of it less as paperwork and more as the first session before the first session.

Ask yourself:

• Does my welcome packet tell someone what to actually expect in our first few sessions, not just my cancellation policy?

• Have I included resources I genuinely trust and use—books, tools, organizations—or is it just filler?

• Does reading this feel like meeting me, or like filling out forms?

• Is there anything missing that I find myself explaining verbally every single intake?

Share

Get into your EHR for real

Most of us learn just enough of our EHR to get through intake and billing and then leave the rest untouched for years. Now is when you go back in.

Automate whatever can be automated. Build out your progress note templates. Set up your intake forms so they’re doing work before the first session even happens. When you’re seeing a full caseload, you will not have the bandwidth to figure this out—and the administrative drag will be real.

Ask yourself:

• Am I retyping anything I could template?

• Do my intake forms collect everything I need before the first session, or am I filling gaps manually?

• How long does a progress note actually take me right now—and what would cut that in half?

• Is there a feature in my EHR I keep meaning to figure out and haven’t?

  ---

Reach out, but do it with intention

This is not the time to cold-email every therapist in a fifty-mile radius. But it is a good time to identify the clinicians whose work you genuinely respect, whose specialties complement yours rather than overlap, and send a real message.

A referral relationship built on actual mutual understanding is worth ten times a generic connection request.

Who are you going to call when a client presents with something outside your lane? Know that before you need it.

And don’t limit yourself to other therapists. Primary care physicians, HR managers, community organizations, wellness practitioners—these are often the first people someone turns to before they ever look up a therapist. Those relationships take time to build. Start now.

Ask yourself:

• What are the two or three presenting concerns I consistently refer out—and do I have someone I trust for each of them?

• Who in my community is already talking to my ideal client before they ever reach a therapist?

• Is my outreach about what I need, or does it open a door to something genuinely mutual?

Knock out your CEUs with some intention

You probably have continuing education hours sitting on your to-do list. Don’t just grab the cheapest bundle to hit the number. Use this window to pursue training that actually deepens your work with the population you’re building toward.

Niche-specific training compounds. It makes you more confident in the room, and that confidence comes through in how you talk about your work—which affects everything from intake calls to referral conversations.

Ask yourself:

• What’s one clinical area where I feel less confident than I’d like to?

• Is there a framework or modality I keep meaning to learn properly rather than just reading about?

• What training would make me more useful to the specific clients I most want to serve?

• Write the content while you have the headspace

If you’re using Substack or any other platform to build your presence as a clinician, this is the moment to batch. Write two, three, four pieces while you have the mental space to do it well. Schedule them out. When your caseload picks up, you will be grateful you did this—because the first thing that goes when you’re busy is the creative work.

Here’s a hot take though: you’ve probably heard the advice to write for your ideal client—to reverse-engineer your content around who you’re trying to attract. And yes, knowing your audience matters. But there’s a version of that advice that gets in your head in the worst way, turning every piece into a marketing calculation instead of an honest one.

The clients who are right for you will find you when you’re clear and when you’re real. You don’t have to perform for them in advance.

Write what you actually think. Share what genuinely lives in your clinical mind. The essay you’re afraid is too specific or too niche or too you is often the one that lands the hardest.

Ask yourself:

• What are the three questions I get asked most often—by clients, supervisees, or colleagues—that I’ve never written down?

• Is there something I wish someone had told me earlier in my career that belongs on the page?

• What’s a piece I’ve been meaning to write that I keep talking myself out of because I’m not sure who it’s for?

Take your own advice about routine

You know what you tell clients about sustainable rhythms. Now practice it.

Map out your ideal week not for when you’re full, but for now—and then actually live it. Building these as habits now means they don’t collapse the moment things get hard.

You are not waiting for permission to structure your days like a person who takes care of themselves. That starts now.

Ask yourself:

• What does my ideal workday look like—and how close is my actual day to that?

• Where do I consistently drop the ball on my own care when things get busy?

• What’s one structural thing I could put in place now that future-me will be grateful for?

Share

The last thing

Try, if you can, to stop calling it waiting. Not because language is magic, but because waiting positions you as someone on the outside looking in—watching for your real life to start.

This is your real life. This is business development time, clinical growth time, foundation-laying time. The work you do right now is exactly what determines what your practice looks and feels like when it’s full.

It counts. Even when it’s quiet.

And yes—I recognize the irony. I literally titled this essay “Things to Do While You Wait.” So let’s make a deal: let’s all work together to stop calling it that. Starting now.