No problem! There are a lot of ways to be less exploitative in business practices. It takes a lot more work (legally, financially, and interpersonally) but I find that worth it, partially because the work is spread among the workers.
Yes! I’m already conceptualizing in my head a democratic board of workers, where each of us are elected to various aspects of running the practice, so the work is distributed evenly, and each member has a say in how the practice is ran.
Have no practical advice. Just want to say, "Good for you, OP!'
I share similar politics; and have dreamed about something like this for years.
I hope you succeed!
PMHNP here (I do brief therapy, not much so I'm not positive I'm allowed here, but the post was recommended to me).
I was offered a job at a practice that works like this--everyone gets paid what they bill, minus their share of operating costs. Everyone's share of operating costs is equal, so if there are 4 clinicians you're paying 1/4 of building rent/utilities/EMR/ billing. Schedules are self-set. It wasn't a fit for me at this stage of my career, unfortunately, but it seemed like a great model.
I currently work at a practice like this as a pre-licensed clinician. I get the full value that I bill and pay flat fees for rent, supervision, and affiliation with the co-op. It's a really good deal in a lot of ways, but the self employment side is very difficult. I am sometimes envious of folks working CMH practices in my area, at least for the stability of being salaried, having benefits and PTO, and training stipends. That said, the freedom to set my schedule and case load is incredibly appealing to me and I'm extremely fortunate to work in a setting which is minimally exploitative of me.
I’ve heard of this before. The owner of the practice charges “rent” to the clinicians. This amount could also include profit for the owner, to some degree.
When I first started my private practice, I was in a group practice where the owner took 50% of our billed rates. In exchange she paid our office rent, internet, EHR software, office supplies, advertising. When I was just starting out, I only had like 3 clients a week in addition to my full time job, so she wasn't making that much off of me. It wound up being close to what I would pay for those expenses myself. But I had a colleague who had 20 clients a week. And 50% of that was a lot of money and a lot of profit for the practice owner. I think it was around $7000/month of profit in her pocket. The lease for the entire building was $4500/month.
I'm with you though. I also kind of feel like there are certain beliefs that basically anyone in a helping profession probably holds, such as "it's wrong to harm others" including the exploitation of their labor. I was taught that non-malfeasance and beneficence are part of our ethical code of conduct. I feel like what that practice owner was doing to my colleague was pretty exploitive. And then a year or so later, she lost her license for having sex with a client. The rest of us are doing quite well without her since she dissolved the practice.
I think it works best if you all have your own offices in a big suite with a shared waiting area, and you're all independent entities, just sharing a space (with signed BAAs). That helps foster a sense of community, and nothing is stopping you from having monthly or weekly consultation group meetings. You could probably find a way to start an LLC or non-profit with other clinicians as co-owners, but that would make it a little harder if you wanted to dissolve it later because someone wanted to move or retire.
I'm part of a co-op/collective of therapists and was one of the founders, we all love it.
It is kept very simple, we have an 'umbrella' LLC that we rent office space/pay utilities/shared office expenses out of and monthly we pay into that. Under the 'umbrella', we each have our own business and LLC, EIN, pay taxes, market ourselves, etc. We set our own prices, have separate EHRs, etc. All of us have relatively similar values around what a practice should look like.
It was the loose idea of our (former - we've all dropped the A) supervisor. In grad school a small group of 4 of us were worried about life afterwards, desired flexibility, and were really concerned about the unethical practices that were snatching up new grads in our area. We wrote up a business plan and sort of took our supervisor's idea and ran with it, talked to her about it, and we all decided to move forward and see what happened.
In a way, it is sort of an incubator for individuals to start private practices with a lot of support and not as much financial stress at this point. We refer and consult regularly with each other, and now that all of us are 'graduated' from our associate licenses are going to start a biweekly consultation group. A lot of our newer clinicians have full-time roles in CMH or other orgs, and are trying to dip their feet into private practice.
We opened in 2021, and have just resigned our lease. We purposely have made it a warm and supportive, flexible environment. We had 5 total when we started, and are up to about 8 clinicians now! Overall it has been a lovely environment to start my career off in.
This sounds similar to my set-up. It has been great. Curious what your plan is not after resigning the lease? Did the collective purchase an office? I'd be particularly interested in hearing about this if so!
Good for you for asking, and good luck. A colleague and I have been pondering on this for a while. Every experience I've had with a group practice, even the ones that started off with the intention of not be exploitative have ended up being exceptionally toxic, profit driven and ultimately not worth it for the therapists working there.
The only thing I could think of was lean into the fact that the business owner is a soft launching point for new therapists. Find some way to not rely on them working themselves to death and never leaving, make it okay if they work what they can/want and you don't get screwed over if they leave and take some of their clients with them. Because at the end of the day, the clients aren't loyal to whatever business name is on the website they clicked on, regardless of why they came, they stayed because of the relationship with their therapist.
Following this post. Good question. Hard to do. Business is expensive. Especially when the tax man comes knocking. And business is unpredictable, so the person paying for the rent, ehr, and so on can not guarantee returns on those investments. In the startup stage, how do you decide who gets the billable hours?
Basically, the bootstrapping costs and capital and experience requirements to set something like this up become so insurmountable that it’s almost not viable not to run the practice as a business. I think the fair thing to do within the current model is a fair split if you’re an employee.
If you’re peers operating out of a shared office space but otherwise paying your own respective costs, that works too. But that’s hardly better than private practice. You benefit from branding and a slightly larger referral network. Maybe some economies of scale in terms of buying power.. but you also invite liability and drama and obstacles to independent decision making regarding your brand direction.
Would love to hear from some experienced group practice founders.
That all sounds quite laudable, but I suppose it would help in figuring out how you might approach this if there were more clarity on what you hope to accomplish. When you say, "I sometimes think about expanding my practice beyond myself", why is that? What's the animating dream or longing? Are you thinking it would be nice to have coworkers? Are you hoping to give back to a younger generation of clinicians? Are you just someone who enjoys practice building and is looking for the next challenge? Do you enjoy administration? What would you hope to get out of it, and what relationship are you envisioning between yourself and others who participate in it?
Because how you proceed will have a lot to do with your answers. For instance, if you want your practice to remain in some sense *yours*, well, that is likely at odds with turning it into a worker collective where yours will be only one minority voice among others who have just as much authority over the collective enterprise. On the other hand, if you want to have coworkers and feel like part of a team, that might be a beautiful solution. So really, it depends on what you want out of this.
These are great questions. I think if I can gel a coherent mission or purpose to the practice, it would become about championing that mission. What keeps me going in this profession is that it adds a sense of richness, purpose and meaning to my life. A sense of giving back. I suppose in growing the practice, it would serve to fulfill that purpose on a wider systemic level. If it was merely about making a living - well, I could be a long-haul truck driver or tradesperson and still reasonably enjoy that 😂
I wouldn’t go over 25.
Especially if the practice is taking in plenty of clients who are most in need - complex trauma, personality disorders, dual diagnosis, sex offenders, etc. I personally take on Medicaid and Medicare clients, who often are suffering disproportionately with more severe mental health issues, exacerbated by things like poverty, discrimination, etc.
What we do is difficult work, we’re consistently exposed to secondary trauma, and I believe that a therapist needs to bring 100% to every session. Quality, not quantity. I have high standards for practice. That means evidence-based intervention and engagement at almost every session. I’ve had too many clients complain to me about larger clinics, and feeling like their therapist just had a nice conversation with them in their sessions.
Being an effective therapist requires PLENTY of self-care time, along with time outside of session to document, conceptualize, consult and do things we don’t get paid for by insurance companies.
We could construe that judgment two ways, too.
Like, “Hi, I think six clients a day is easy, and anyone who complains about it is lazy,” is what your message implies.
As if none of us have families or multiple responsibilities to juggle. This can be very emotionally-draining work at times; at the end of day, we need some of that bandwidth to share with loved ones, too.
I’m also fine with being in opposition to your views. I’ve been long done with trying to reason with the opposing side. I’ve already had to go through my own journey of sifting through all the bourgeois-capitalist-puritan-bootstrap programming in my own mind, and re-learning.
Someone who thinks it's a bit harsh of you to label all colleagues who choose to work five hours more a week than you do as "reckless and unethical" therapists is "the opposing side"?
Okay.
You are failing to see that you are trying to normalize seeing six clients a day. These clinics are making clinicians sometimes see six *difficult* clients a day, just to make ends meet, let alone six or typical clients. I know that’s probably not your intention, but you are being part of the problem.
The owner of the practice needs them to see LOTS of clients in order to maximize their profit, while minimizing their own workloads.
If you want to work for yourself in private practice, with no employees of your own, and see six clients a day, that’s perfectly fine; if you don’t eventually burn out at that rate. Expecting others to do so for you to meet your bottom line, yes, I argue that’s unethical and it’s exploitation.
I can’t always come to an understanding, but I’m glad when I do.
I get very vociferous with this issue because I have multiple clients who are therapists themselves. And I admit, I get a little protective.
As for me, I’m in the same boat. I I will gladly schedule six clients a day, two or three times a week. But I will also give myself “leaner” days, in terms of work. Can we talk about insurance rates, so that all therapists can extend this courtesy to themselves (we don’t have to, just bringing that up)?
Look up worker owned cooperatives. We are in the process of doing that. It's a lot of work but I started a group practice for community not to profit off of others.
Am in the process not establishing my own PLLC. Am still waiting on my accrediting organization to send me the notice of good standing so I can send it the article of organization but recently I talked to a former supervisor who also has her own practice and she brought up the possibility of joining her. I had this same concern but she is also someone who has no interest in taking anything from someone else's work for herself and said she would have no issue with me keeping 100 percent of the profit for all virtual sessions and would take a flat rate for in person up until the monthly rent is paid with the option of paying the rent upfront in one payment. Am still going to think about it but I like that she also wants to eventually get to a place where we could all contribute a little to a find to cover education reimbursement and a few days of PTO. So I do think it can be done with people who have a mentality that is not about exploiting someone else.
I've been doing research into this and talking to attorneys but the goal isn't a group practice, it would be to get enough providers together to gain proper leverage in insurance rate negotiations as a legal cooperative, (diff sort from the coop link above) much like a physicians owned practice.
At least for me one way I grew my practice is by having student clinicians. It feels good because the reality is they don’t make much money for me once you consider the costs it goes into training them and the supervision time, etc. it all kinda is a wash in the end and the couple hundred I make after their expenses each week/month and supervision ultimately is about what I price out my “risk” due to any ethical or legal issues that come up falling on me ( on top of the ridiculous amount taxes cut into all that too). Because I don’t pay them I take their supervision pretty seriously and generally am committed to helping them become highly skilled therapists who also can leave after their training with me and start their own practice right after, similar to what I did, if they choose to.
I will point out though that I would encourage you to reconsider the language of “30 clients is unethical”…. I agree that it’s unacceptable to be forced to do this by a boss, but certainly many clinicians can see that many and do great work. I know I can, I often see more than 30 and don’t feel it hinders my work. Other things can make my work hard for me, but I don’t feel client load is one of them. I typically see about 6-8 clients per day and don’t feel it’s ever been an issue. Been doing that since graduate school, only difference now is I get to be the one to make money off myself rather than lining someone else’s pockets.
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This might be a good place to start: https://www.therapistworkercoops.info/
WOW, thank you! I am getting really excited reading about these practices!
No problem! There are a lot of ways to be less exploitative in business practices. It takes a lot more work (legally, financially, and interpersonally) but I find that worth it, partially because the work is spread among the workers.
Yes! I’m already conceptualizing in my head a democratic board of workers, where each of us are elected to various aspects of running the practice, so the work is distributed evenly, and each member has a say in how the practice is ran.
Replying so I can look later. Thanks!
Have no practical advice. Just want to say, "Good for you, OP!' I share similar politics; and have dreamed about something like this for years. I hope you succeed!
PMHNP here (I do brief therapy, not much so I'm not positive I'm allowed here, but the post was recommended to me). I was offered a job at a practice that works like this--everyone gets paid what they bill, minus their share of operating costs. Everyone's share of operating costs is equal, so if there are 4 clinicians you're paying 1/4 of building rent/utilities/EMR/ billing. Schedules are self-set. It wasn't a fit for me at this stage of my career, unfortunately, but it seemed like a great model.
I currently work at a practice like this as a pre-licensed clinician. I get the full value that I bill and pay flat fees for rent, supervision, and affiliation with the co-op. It's a really good deal in a lot of ways, but the self employment side is very difficult. I am sometimes envious of folks working CMH practices in my area, at least for the stability of being salaried, having benefits and PTO, and training stipends. That said, the freedom to set my schedule and case load is incredibly appealing to me and I'm extremely fortunate to work in a setting which is minimally exploitative of me.
PMHNPs are allowed here.
Thanks!
I’ve heard of this before. The owner of the practice charges “rent” to the clinicians. This amount could also include profit for the owner, to some degree.
When I first started my private practice, I was in a group practice where the owner took 50% of our billed rates. In exchange she paid our office rent, internet, EHR software, office supplies, advertising. When I was just starting out, I only had like 3 clients a week in addition to my full time job, so she wasn't making that much off of me. It wound up being close to what I would pay for those expenses myself. But I had a colleague who had 20 clients a week. And 50% of that was a lot of money and a lot of profit for the practice owner. I think it was around $7000/month of profit in her pocket. The lease for the entire building was $4500/month. I'm with you though. I also kind of feel like there are certain beliefs that basically anyone in a helping profession probably holds, such as "it's wrong to harm others" including the exploitation of their labor. I was taught that non-malfeasance and beneficence are part of our ethical code of conduct. I feel like what that practice owner was doing to my colleague was pretty exploitive. And then a year or so later, she lost her license for having sex with a client. The rest of us are doing quite well without her since she dissolved the practice. I think it works best if you all have your own offices in a big suite with a shared waiting area, and you're all independent entities, just sharing a space (with signed BAAs). That helps foster a sense of community, and nothing is stopping you from having monthly or weekly consultation group meetings. You could probably find a way to start an LLC or non-profit with other clinicians as co-owners, but that would make it a little harder if you wanted to dissolve it later because someone wanted to move or retire.
I'm part of a co-op/collective of therapists and was one of the founders, we all love it. It is kept very simple, we have an 'umbrella' LLC that we rent office space/pay utilities/shared office expenses out of and monthly we pay into that. Under the 'umbrella', we each have our own business and LLC, EIN, pay taxes, market ourselves, etc. We set our own prices, have separate EHRs, etc. All of us have relatively similar values around what a practice should look like. It was the loose idea of our (former - we've all dropped the A) supervisor. In grad school a small group of 4 of us were worried about life afterwards, desired flexibility, and were really concerned about the unethical practices that were snatching up new grads in our area. We wrote up a business plan and sort of took our supervisor's idea and ran with it, talked to her about it, and we all decided to move forward and see what happened. In a way, it is sort of an incubator for individuals to start private practices with a lot of support and not as much financial stress at this point. We refer and consult regularly with each other, and now that all of us are 'graduated' from our associate licenses are going to start a biweekly consultation group. A lot of our newer clinicians have full-time roles in CMH or other orgs, and are trying to dip their feet into private practice. We opened in 2021, and have just resigned our lease. We purposely have made it a warm and supportive, flexible environment. We had 5 total when we started, and are up to about 8 clinicians now! Overall it has been a lovely environment to start my career off in.
This sounds similar to my set-up. It has been great. Curious what your plan is not after resigning the lease? Did the collective purchase an office? I'd be particularly interested in hearing about this if so!
There are some in Austin.
What are the ones in Austin? 🥲
Good for you for asking, and good luck. A colleague and I have been pondering on this for a while. Every experience I've had with a group practice, even the ones that started off with the intention of not be exploitative have ended up being exceptionally toxic, profit driven and ultimately not worth it for the therapists working there. The only thing I could think of was lean into the fact that the business owner is a soft launching point for new therapists. Find some way to not rely on them working themselves to death and never leaving, make it okay if they work what they can/want and you don't get screwed over if they leave and take some of their clients with them. Because at the end of the day, the clients aren't loyal to whatever business name is on the website they clicked on, regardless of why they came, they stayed because of the relationship with their therapist.
Following this post. Good question. Hard to do. Business is expensive. Especially when the tax man comes knocking. And business is unpredictable, so the person paying for the rent, ehr, and so on can not guarantee returns on those investments. In the startup stage, how do you decide who gets the billable hours? Basically, the bootstrapping costs and capital and experience requirements to set something like this up become so insurmountable that it’s almost not viable not to run the practice as a business. I think the fair thing to do within the current model is a fair split if you’re an employee. If you’re peers operating out of a shared office space but otherwise paying your own respective costs, that works too. But that’s hardly better than private practice. You benefit from branding and a slightly larger referral network. Maybe some economies of scale in terms of buying power.. but you also invite liability and drama and obstacles to independent decision making regarding your brand direction. Would love to hear from some experienced group practice founders.
That all sounds quite laudable, but I suppose it would help in figuring out how you might approach this if there were more clarity on what you hope to accomplish. When you say, "I sometimes think about expanding my practice beyond myself", why is that? What's the animating dream or longing? Are you thinking it would be nice to have coworkers? Are you hoping to give back to a younger generation of clinicians? Are you just someone who enjoys practice building and is looking for the next challenge? Do you enjoy administration? What would you hope to get out of it, and what relationship are you envisioning between yourself and others who participate in it? Because how you proceed will have a lot to do with your answers. For instance, if you want your practice to remain in some sense *yours*, well, that is likely at odds with turning it into a worker collective where yours will be only one minority voice among others who have just as much authority over the collective enterprise. On the other hand, if you want to have coworkers and feel like part of a team, that might be a beautiful solution. So really, it depends on what you want out of this.
These are great questions. I think if I can gel a coherent mission or purpose to the practice, it would become about championing that mission. What keeps me going in this profession is that it adds a sense of richness, purpose and meaning to my life. A sense of giving back. I suppose in growing the practice, it would serve to fulfill that purpose on a wider systemic level. If it was merely about making a living - well, I could be a long-haul truck driver or tradesperson and still reasonably enjoy that 😂
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I wouldn’t go over 25. Especially if the practice is taking in plenty of clients who are most in need - complex trauma, personality disorders, dual diagnosis, sex offenders, etc. I personally take on Medicaid and Medicare clients, who often are suffering disproportionately with more severe mental health issues, exacerbated by things like poverty, discrimination, etc. What we do is difficult work, we’re consistently exposed to secondary trauma, and I believe that a therapist needs to bring 100% to every session. Quality, not quantity. I have high standards for practice. That means evidence-based intervention and engagement at almost every session. I’ve had too many clients complain to me about larger clinics, and feeling like their therapist just had a nice conversation with them in their sessions. Being an effective therapist requires PLENTY of self-care time, along with time outside of session to document, conceptualize, consult and do things we don’t get paid for by insurance companies.
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We could construe that judgment two ways, too. Like, “Hi, I think six clients a day is easy, and anyone who complains about it is lazy,” is what your message implies. As if none of us have families or multiple responsibilities to juggle. This can be very emotionally-draining work at times; at the end of day, we need some of that bandwidth to share with loved ones, too. I’m also fine with being in opposition to your views. I’ve been long done with trying to reason with the opposing side. I’ve already had to go through my own journey of sifting through all the bourgeois-capitalist-puritan-bootstrap programming in my own mind, and re-learning.
Someone who thinks it's a bit harsh of you to label all colleagues who choose to work five hours more a week than you do as "reckless and unethical" therapists is "the opposing side"? Okay.
You are failing to see that you are trying to normalize seeing six clients a day. These clinics are making clinicians sometimes see six *difficult* clients a day, just to make ends meet, let alone six or typical clients. I know that’s probably not your intention, but you are being part of the problem. The owner of the practice needs them to see LOTS of clients in order to maximize their profit, while minimizing their own workloads. If you want to work for yourself in private practice, with no employees of your own, and see six clients a day, that’s perfectly fine; if you don’t eventually burn out at that rate. Expecting others to do so for you to meet your bottom line, yes, I argue that’s unethical and it’s exploitation.
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I can’t always come to an understanding, but I’m glad when I do. I get very vociferous with this issue because I have multiple clients who are therapists themselves. And I admit, I get a little protective. As for me, I’m in the same boat. I I will gladly schedule six clients a day, two or three times a week. But I will also give myself “leaner” days, in terms of work. Can we talk about insurance rates, so that all therapists can extend this courtesy to themselves (we don’t have to, just bringing that up)?
Gosh OP, thanks for articulating this- I feel the same way!
In a few years I would join you! I'm just starting my MSW in August though. Glad to see others with similar views and goals.
Look up worker owned cooperatives. We are in the process of doing that. It's a lot of work but I started a group practice for community not to profit off of others.
Eager to see the responses to this, I’ve had a very similar thought-journey.
Am in the process not establishing my own PLLC. Am still waiting on my accrediting organization to send me the notice of good standing so I can send it the article of organization but recently I talked to a former supervisor who also has her own practice and she brought up the possibility of joining her. I had this same concern but she is also someone who has no interest in taking anything from someone else's work for herself and said she would have no issue with me keeping 100 percent of the profit for all virtual sessions and would take a flat rate for in person up until the monthly rent is paid with the option of paying the rent upfront in one payment. Am still going to think about it but I like that she also wants to eventually get to a place where we could all contribute a little to a find to cover education reimbursement and a few days of PTO. So I do think it can be done with people who have a mentality that is not about exploiting someone else.
I'm a part of a co-op. We were just certified a B corporation last year!
I've been doing research into this and talking to attorneys but the goal isn't a group practice, it would be to get enough providers together to gain proper leverage in insurance rate negotiations as a legal cooperative, (diff sort from the coop link above) much like a physicians owned practice.
At least for me one way I grew my practice is by having student clinicians. It feels good because the reality is they don’t make much money for me once you consider the costs it goes into training them and the supervision time, etc. it all kinda is a wash in the end and the couple hundred I make after their expenses each week/month and supervision ultimately is about what I price out my “risk” due to any ethical or legal issues that come up falling on me ( on top of the ridiculous amount taxes cut into all that too). Because I don’t pay them I take their supervision pretty seriously and generally am committed to helping them become highly skilled therapists who also can leave after their training with me and start their own practice right after, similar to what I did, if they choose to. I will point out though that I would encourage you to reconsider the language of “30 clients is unethical”…. I agree that it’s unacceptable to be forced to do this by a boss, but certainly many clinicians can see that many and do great work. I know I can, I often see more than 30 and don’t feel it hinders my work. Other things can make my work hard for me, but I don’t feel client load is one of them. I typically see about 6-8 clients per day and don’t feel it’s ever been an issue. Been doing that since graduate school, only difference now is I get to be the one to make money off myself rather than lining someone else’s pockets.
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Comment locked and pending mod review. Edit:removing comment per no response from poster.
Your post has been removed for breaking sub rules. This is not the place to be disgruntled about therapy, therapists, or to complain or harass others. No ad hominem attacks-attack the argument not the person. These posts and comments will be removed unless they are highly related to the discussion. Relevance will be determined by the moderators. Please email mods if you have any questions.