The State of Therapy: Surviving, Thriving, and (Un)Learning the Rules
Welcome to "Starting a Counseling Practice Success Stories"! In this State of the Union episode, hosts Kelly Higdon and Miranda Palmer tackle the latest shifts in mental health care and how they affect private practice owners. From the push toward value-based care and what that means for therapist pay and accountability, to the personal impact of working in an increasingly profit-driven system, Kelly and Miranda get real about insurance, outcomes, and the emotional cost of navigating broken structures.
You’ll get insights on tracking client improvement, negotiating with insurance, and building a sustainable practice that supports your clients—and yourself. Tune in for honest discussion, practical tips, and encouragement for therapists striving to create positive change in a challenging environment.
00:00 "Understanding Value-Based Care Concepts"
03:19 Therapist Payment Issues and Challenges
09:02 UHC: Profitable Yet Problematic Partnerships
13:10 Therapists' Fear-Induced Behavioral Shift
17:23 "Burnout vs. Mental Health Diagnosis"
20:27 Decolonizing Practice for Healing
25:03 Holistic Support Over Self-Care
26:58 Balancing Business and Community Support
29:59 Navigating Private Practice Challenges
33:43 Evaluating Therapy Success Metrics
39:30 "Orlando's Top Trauma Therapists"
42:03 Therapists' Anxiety and Outcome Improvement
43:56 "Recognizing Progress Beyond Trauma"
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Transcript
Kelly Higdon (She/They): Welcome back to another episode.
Speaker:This one is just myself, Kelly and Miranda talking about what's happening
Speaker:in the world of mental health care and how it's impacting private practice.
Speaker:We have some more fun things to share today.
Speaker:Miranda Palmer (She/Her): Kelly sent me a wonderful article last,
Speaker:uh, last night about the North Star of behavioral health aligning payer
Speaker:provider goals in value-based care.
Speaker:What is value-based care?
Speaker:Kelly, and can we talk about it?
Speaker:Kelly Higdon (She/They): It means that basically like we're looking at how
Speaker:payment is determined between you, the provider and the insurance company,
Speaker:um, and looking at a value-based care arrangement, meaning that you assign some
Speaker:sort of value to the therapy and determine that you'll be paid based upon that value.
Speaker:Is that the best?
Speaker:I'm not the best at explaining things.
Speaker:Did I do okay.
Speaker:Miranda Palmer (She/Her): Okay.
Speaker:But I think, I think there, I pulled out some quotes that I think are really,
Speaker:um, I want you guys to listen to, and this is from, from this article.
Speaker:We'll, we'll post it in the show notes.
Speaker:Um, a value-based care arrangement can do many things, including
Speaker:those are their words, full risk.
Speaker:Full risk for the, for the provider pay for performance.
Speaker:Mm-hmm.
Speaker:You get paid based on your performance or even shared
Speaker:savings, whatever that might mean.
Speaker:Right.
Speaker:Um, now here's a another quote that I think is really juicy.
Speaker:And this is from one of the CEOs, this guy Henry.
Speaker:I'm really interested in shared risk models because they have so
Speaker:much more potency to change beha, uh, provider behavior rapidly.
Speaker:So let's talk about this.
Speaker:I just makes me
Speaker:Kelly Higdon (She/They): mad because what it feels like is this, them
Speaker:saying like, I have, it's almost like.
Speaker:I have spiritually bypassed my accountability and
Speaker:responsibility as a corporation.
Speaker:This is like capitalism to the hilt of like, I've made it, okay.
Speaker:In my mind, I have created this like story in my head as why this is so good
Speaker:for the client, and I'm not saying that.
Speaker:We should be tracking outcomes.
Speaker:Getting great results is important.
Speaker:Yeah, I agree with that.
Speaker:But the logic of corporate America and capitalism, it irks me to no end.
Speaker:Like
Speaker:Miranda Palmer (She/Her): seriously, I put this article into chat GPT.
Speaker:You did?
Speaker:Oh, I did.
Speaker:I put this article in the shot GBT and I said, Hey, given what you know
Speaker:about therapists, what do you think?
Speaker:About this article and therapists taking on more risk.
Speaker:Here's what chat GPT said, okay, therapists already absorb
Speaker:a disproportionate amount of risk in insurance-based care.
Speaker:They sometimes wait months to be reimbursed, if at all.
Speaker:They face clawback for care.
Speaker:They've that have already been delivered.
Speaker:They rarely have transparency into why claims are denied.
Speaker:They get paid far beyond their value with stagnant rates for years and are burdened
Speaker:with unpaid admin time, documentation, treatment plans, and audits.
Speaker:Now, let's talk about this piece really quickly 'cause
Speaker:there's another article that.
Speaker:I ended up getting linked to, from something that came out from civil
Speaker:practice overnight about the rates of how therapists are being paid.
Speaker:So there was a research article done, um, a few years ago, price and cost sharing
Speaker:for psychotherapy in network versus out of network in the United States.
Speaker:Um, over the 11 year study period, the use of adult psychotherapy increased.
Speaker:Um, it went from an average of 34 visits per 100 enrollees to 54 enrollees.
Speaker:And the in, uh, the negotiated prices declined by 13.9%.
Speaker:Over the 11 year period, so as your costs have been increasing, overarching in
Speaker:network rates have been already declining.
Speaker:And what they're saying is they want the option to reduce your rates even further
Speaker:and to make it a, you have to figure out how to get paid based on their.
Speaker:Scenarios.
Speaker:Right?
Speaker:So what does this mean?
Speaker:I think what, what, what is a good outcome for a for-profit health insurance company?
Speaker:A good outcome for them is that people don't come back to therapy.
Speaker:Right?
Speaker:Like that's a good outcome for them.
Speaker:I had this, I'm so sorry to be talking so much, but this is like I, I had this
Speaker:situation once I worked for the county.
Speaker:My supervisor, who's no longer a therapist, um, was also in private
Speaker:practice and they had a contract with an EAP and the EAP paid them
Speaker:$99 for up to three sessions for EAP services, and you would go,
Speaker:oh, $99 for up to three sessions.
Speaker:Um, $99 per session, right.
Speaker:No, they were paid $99.
Speaker:Whether the person came one time or three times, guess what this
Speaker:therapist said that they did?
Speaker:They would only see somebody once and then they would for refer them out and
Speaker:tell them they didn't need additional services because they said, quote, I
Speaker:can't afford to see them more than once.
Speaker:That's what, that's what happens, right?
Speaker:You create a dynamic where somebody is.
Speaker:Really like the, the whole outcome is how do I get somebody out of therapy as
Speaker:quickly as possible, not how do I get somebody better as quickly as possible?
Speaker:In my humble opinion,
Speaker:Kelly Higdon (She/They): this is the quote that struck me from this
Speaker:article was when they were talking about, well, what did they measure?
Speaker:What's the value that they look at for therapy?
Speaker:And it says, we measure a laundry list of items.
Speaker:What we have found so far is the number one measure that we can execute
Speaker:against that drives total cost of care.
Speaker:Savings is therapeutic alliance.
Speaker:So as we look at what that means, we understand that to be three
Speaker:sessions with the same therapist within a defined period of time.
Speaker:And we've actually been able to demonstrate with one of our
Speaker:payer partners that drives down total cost of care by up to 20%.
Speaker:Um, turning that into a number is like $1,800.
Speaker:So.
Speaker:This sounds like, oh, they're gonna pay me because I get great outcomes.
Speaker:No, they wanna pay you to save them money.
Speaker:They're not interested in covering our healthcare.
Speaker:They're interested in profit.
Speaker:And so if like three sessions within a defined period is what they use
Speaker:to determine therapeutic alliance.
Speaker:Okay.
Speaker:I'm gonna,
Speaker:Miranda Palmer (She/Her): but I, go ahead.
Speaker:Kelly Higdon (She/They): I
Speaker:Miranda Palmer (She/Her): think I actually, I actually hear that
Speaker:in a different way, which is.
Speaker:Basically, if you are a therapist who can get people to come in three times
Speaker:in a shorter period of time, that generally, like the therapeutic alliance
Speaker:and someone to gauge people in therapy has the best like overarching outcome.
Speaker:Yes.
Speaker:Kelly Higdon (She/They): Okay.
Speaker:Maybe let me rephrase this, but it's not really about therapeutic alliance.
Speaker:It's not, that's what I'm saying.
Speaker:This is sort of that kind of.
Speaker:They make this moral high ground, which is really not, it's false.
Speaker:It is about their savings.
Speaker:That's what they care about.
Speaker:Are you as a provider going to save them money?
Speaker:I remember when I worked inpatient and Kaiser, I had all the Kaiser patients
Speaker:on the child and adolescent unit.
Speaker:And on some of the adult units, but I was the primary therapist
Speaker:for the child and adolescent.
Speaker:And if a child stayed beyond five days, they would send a nurse, a
Speaker:mental health nurse from Kaiser Corporate to come and talk to the
Speaker:child about how they needed to get it together basically and get outta here.
Speaker:Right.
Speaker:Even if the child was actively suicidal.
Speaker:Right.
Speaker:Because to them it's not like, how are you doing?
Speaker:Is this actually effective and we are progressing.
Speaker:That's great.
Speaker:No, it's about the savings.
Speaker:And so it's this interesting, like it just feels, hey, we care about outcomes.
Speaker:No, we care about saving.
Speaker:So,
Speaker:Miranda Palmer (She/Her): and, and this is the piece when you have
Speaker:publicly traded companies, right?
Speaker:We have publicly trained, traded for profit companies who, some
Speaker:of that money that is actually.
Speaker:That these organizations are going on are, are, are living on, is
Speaker:actual government contracts, right?
Speaker:UHC actually does a huge amount of business with the United States government
Speaker:because they have taken on some of their medical and mental health, um,
Speaker:services through their company, right?
Speaker:But again, what do we know if you've ever worked for UHC, um, as a therapist?
Speaker:This is some, some contracts.
Speaker:Some provider or some, um, mental health contracts are a little better
Speaker:in certain states versus other states.
Speaker:Um, UHC is one that I haven't met a provider yet.
Speaker:That's like UHC is great to work with.
Speaker:They really pay me well.
Speaker:Um, and I don't have to, to do anything.
Speaker:And I'm able to really make sure I'm providing my clients the
Speaker:best, the best outcomes possible.
Speaker:And I, I get paid well.
Speaker:Right?
Speaker:Like that just.
Speaker:So I have not heard that for UHC and who's number one for years of the, the
Speaker:most profitable health insurance company.
Speaker:It's been UnitedHealthcare.
Speaker:I mean, honestly, for you as a therapist, if we were to go back 10
Speaker:years, your best investment if you were working with insurance would've
Speaker:been to invest in UnitedHealthcare.
Speaker:Put any a hundred dollars a month into UnitedHealthcare, that would've given you
Speaker:more profitability in your business as a stockholder than as a person actually
Speaker:working for them in, in my humble opinion.
Speaker:Yeah, I, we should run those numbers.
Speaker:I think that'd be really interesting.
Speaker:Maybe I'll talk with my, my friend who has the, the, the materials
Speaker:to say, what if you had done this?
Speaker:Like, what if you hadn't worked?
Speaker:Or like, if you're working for UnitedHealthcare,
Speaker:here's what this looks like.
Speaker:Um, and here's what it looks like if you were an investor, which would make
Speaker:you, uh, actually be able to, to retire or to actually just pay your bills.
Speaker:Kelly Higdon (She/They): Yeah.
Speaker:So I think like when we look at these value-based contracts.
Speaker:There's other things that they're also talking about in terms of like,
Speaker:uh, readmission, like returning back to services, length of treatment,
Speaker:how long like a person might not be able to work and things like that.
Speaker:And we are hearing about like private practice owners being able to get higher
Speaker:rates based on outcomes driven care.
Speaker:So this is something we teach a lot in our business school about having
Speaker:outcomes, conversations, not just for integrating in your marketing,
Speaker:but really to create a, a cycle of a feedback loop of excellence, right?
Speaker:So that I take in feedback, I make changes within the way I provide care.
Speaker:So clinical outcomes continue to improve.
Speaker:And insurance companies do want to reward that, right?
Speaker:They are like, they want their clients to get.
Speaker:In and out of care faster to see improvement faster again.
Speaker:Not 'cause they care about their client per se, they
Speaker:care about their cost savings.
Speaker:I just wanna keep hitting that home because they make it look like they
Speaker:really do really care about us people.
Speaker:But, uh, this is going to be, I think, more and more of a strategy
Speaker:for, um, insurance companies, which then leads to what happens when
Speaker:certain outcome measures aren't met.
Speaker:Yeah.
Speaker:And if you will get paid.
Speaker:Miranda Palmer (She/Her): Will you get, I mean, uh, again, let's
Speaker:go back to this language that I, that I read out before, right?
Speaker:Who takes the risk?
Speaker:Miranda, I'm really interested in shared risk models because
Speaker:they have so much more potency to change provider behavior rapidly.
Speaker:Right.
Speaker:So they would,
Speaker:Kelly Higdon (She/They): they would change my stress level rapidly.
Speaker:Miranda Palmer (She/Her): I mean, I have watched this in terms of when
Speaker:we talk about like the, the risk models I've watched where particular
Speaker:companies started doing, uh, like assessments or sending out letters.
Speaker:Basically if you were doing 53 plus minute.
Speaker:Services for every CPT code.
Speaker:They were sending out this letter and throwing therapists into a panic attack.
Speaker:And so did it change the behavior for a lot of therapists just out of fear
Speaker:that they were gonna get clawbacks or they weren't gonna be reimbursed?
Speaker:A lot of therapists changed their behavior.
Speaker:To do shorter sessions just based out of that, even if it wasn't really accurate,
Speaker:even if there was no teeth around it.
Speaker:So yes, giving therapists that are already underpaid and overworked.
Speaker:Fear about not getting paid.
Speaker:Is it going to change behavior?
Speaker:Uh, provider behavior?
Speaker:I think probably yes, but maybe not in the way that you think it is.
Speaker:I think more therapists may decide to leave.
Speaker:These organizations and to say, no thank you.
Speaker:I don't want to be a part of this.
Speaker:And I think ultimately that could lead to insurance companies realizing that
Speaker:while, yes, we have been happily the worst paid master's degrees for 20 plus
Speaker:years, there is a, there is a point.
Speaker:There is a stopping point where we say like, no, I can't take any more risk.
Speaker:I'm already working paycheck to paycheck.
Speaker:I have no retirement in place.
Speaker:I'm already overworking like this is enough.
Speaker:I already have.
Speaker:You know how tens or hundred hundreds of thousands of dollars in student
Speaker:loans of risk that I assume that I'm supposed to try to figure out how to
Speaker:pay back, that I'm never gonna pay back because I'm an income based repayment
Speaker:and then my income doesn't connect.
Speaker:Like I'm already, I've already got all the risk I can't take anymore.
Speaker:Kelly Higdon (She/They): Mm-hmm.
Speaker:And I think that that's the common theme in private practice and
Speaker:just for therapists in general.
Speaker:Is that we continuously stand, try to stand in the gap of systems that
Speaker:are larger than us, more profitable than us, and far more broken.
Speaker:And we think, oh, I, I have to be the one to do this.
Speaker:You know that I'm the one that has to like see the people even though their
Speaker:insurance sucks or you know, like stand.
Speaker:And, and fix it and what the cost to that is.
Speaker:So great that we see it over and over with therapists developing autoimmune
Speaker:conditions that are in debt that are, um.
Speaker:They're struggling with their own mental health, quite frankly.
Speaker:It's hard enough, like right now, I think doing therapy while you're simultaneously
Speaker:going through what your clients are going through, you know, there's more
Speaker:and more of that thematically with our e economy and the government and, and
Speaker:everything that's going on in the world, let alone then trying as an individual
Speaker:business, as a, as a person, just a human being, trying to say, I can fix.
Speaker:This like healthcare issue in our country.
Speaker:Miranda Palmer (She/Her): Okay.
Speaker:I love that you brought up this idea of medical and mental health impact
Speaker:on the therapist, on the provider.
Speaker:Um, can we talk about that a little bit more?
Speaker:So.
Speaker:You know, we wrote a book on therapist burnout.
Speaker:We did?
Speaker:No, I know.
Speaker:We wrote the book.
Speaker:No.
Speaker:We wrote a book on therapist burnout and did a ton of research, um, regarding
Speaker:like, what does burnout really mean?
Speaker:What does it really look like?
Speaker:And one of the things that I really was left with after.
Speaker:Researching this idea of burnout and even some of the reasons why burnout
Speaker:has not been included in our dsm.
Speaker:Our DSM, even though it's seen as an issue at the World Health Organization,
Speaker:right, is because the biggest difference between burnout and a lot
Speaker:of our mental health diagnoses is not the symptomology, but the etymology.
Speaker:Right.
Speaker:So is it that you have major depression disorder or is it that you're burned
Speaker:out from working within a broken system?
Speaker:And if you are working within a broken system, and that is what is fueling
Speaker:your symptoms, it will SSRIs help?
Speaker:Will therapy help?
Speaker:Will anything help if you're staying within the system?
Speaker:It's sort of that same place of saying, well, you know, this person has.
Speaker:Generalized anxiety disorder, um, and wow, we can't get them
Speaker:stabilized on medications.
Speaker:It's, it's really, really difficult.
Speaker:And then you dive in a little deeper and you find out this person is an
Speaker:active, unsafe environment, there's domestic violence inside the home.
Speaker:Do you keep trying to manage their anxiety about living in an unsafe situation?
Speaker:Or do you say, actually probably the only thing that's going to quote unquote fix
Speaker:the anxiety is them being in a safe home.
Speaker:Right?
Speaker:So like, what does that look like for us as therapists?
Speaker:If we started to really ask the question of, am I really depressed,
Speaker:anxious, um, is that really here?
Speaker:Is, is that really the core of it, that this is just.
Speaker:A medical condition, something that's maybe genetic or just a, a
Speaker:part of this, or is this a normal physiological response, response
Speaker:to dumpster, fire, broken system, and is my autoimmune condition?
Speaker:The next stage in that response that says, Hey, I couldn't get you to listen.
Speaker:The system hasn't changed.
Speaker:Yeah.
Speaker:So I'm gonna keep pulling back the energy and shutting systems
Speaker:down until something changes.
Speaker:Kelly Higdon (She/They): It just breaks my heart.
Speaker:Like I could actually cry because I, I mean, I was one of those people, right?
Speaker:Ended up in the hospital with, uh.
Speaker:Paralyzed with my migraines and all sorts of things.
Speaker:You know, chronic pain and fibromyalgia and just a host of things.
Speaker:And it's taken a long time to unravel that, and I think that is
Speaker:why I do love private practice.
Speaker:I'm not saying it's a perfect solution.
Speaker:I'm not saying that we aren't still functioning within a broken system,
Speaker:even as a small business owner.
Speaker:But what becomes more of within my creative control and within my,
Speaker:my sovereignty, um, is, you know, creating a business that actually, a
Speaker:system that actually supports me and my body and my nervous system in a
Speaker:way that capitalistic corporations.
Speaker:Cannot do that and will not do that.
Speaker:They never will.
Speaker:And it's like an abusive relationship.
Speaker:Still hoping that it'll be different, that one day it'll get better or
Speaker:this benefits package will make me, you know, all the things.
Speaker:Um, and so I feel like that is where.
Speaker:Private practice can be healing if we don't replicate those
Speaker:systems within our practice.
Speaker:Of course.
Speaker:Right?
Speaker:That's the hard part.
Speaker:Sometimes we've learned this way.
Speaker:This is why I love stuff, uh, you know, around decolonizing therapy, decolonizing
Speaker:business, and you and I have been, you know, on a journey of decolonizing our
Speaker:businesses and it's, it's an ongoing, this will be the rest of our lives,
Speaker:y'all, because it's so ingrained, but.
Speaker:The more we do that, the more that we can create a healing place for us and,
Speaker:and a healing place for our clients, but also for us, we heal through this
Speaker:kind of work too, like creating a system that does fully support us.
Speaker:Miranda Palmer (She/Her): Yeah, I mean, I, I've been, well, I don't
Speaker:know if I've been public on the podcast about having Hashimoto's
Speaker:and it's, it is really impactful.
Speaker:Um, it, and it's.
Speaker:Not a surprising thing that when it popped up was not only after having a child, but
Speaker:also starting a private practice or you know, like starting down this path, right?
Speaker:Where I could again, replicate my overwork.
Speaker:Where I could go from, okay, wait, I'm already like in this broken
Speaker:place, I'm already like struggling and now I'm putting more, more
Speaker:onto my body, um, in this dynamic.
Speaker:So to be able to unravel that over time and to go from.
Speaker:When I initially started my private practice, I would see 10 clients a day.
Speaker:Kelly Higdon (She/They): I did too,
Speaker:Miranda Palmer (She/Her): back to back five clients before I would
Speaker:start sometimes at six in the morning.
Speaker:Right.
Speaker:And again, I, in my mind initially this was so much better because I
Speaker:had time off to be with my infant.
Speaker:Mm-hmm.
Speaker:Right?
Speaker:Like I'm thinking I'm unraveling the system even within that.
Speaker:But like, here's how.
Speaker:You know, shifted my voice, my, my scenario was where I'm doing that while
Speaker:also working for, uh, teaching at local universities in person and online,
Speaker:while also being the primary caregiver for an infant and breastfeeding.
Speaker:Right?
Speaker:Like, these are the levels of like how, how interesting and
Speaker:insidious the, the space is, right.
Speaker:And the amount of time that it took.
Speaker:For my, for me to unravel and get to a Hashimoto's
Speaker:diagnosis was absolutely insane.
Speaker:And, and very, um, I definitely had doctors who would kind of gaslight me
Speaker:into saying, okay, so you were depressed.
Speaker:Okay, you're anxious.
Speaker:Let's get you on a, on a antidepressant.
Speaker:Let's get you on a anti-anxiety.
Speaker:And I'm like, I don't think that's what this is like.
Speaker:I have a huge thyroid issue in my family, and they're like, your thyroid is fine.
Speaker:My thyroid levels on the surface were fine, but my antibodies were not fine.
Speaker:And so as soon as we got into that space, and even the way my
Speaker:symptomology came up, where I would get vertigo, where I would get.
Speaker:Dizzy.
Speaker:Driving myself around town, like I would get car sick, driving myself around
Speaker:town and I had to go to a naturopathic doctor, was the first person where
Speaker:I said, Hey, I have these symptoms.
Speaker:It's really crazy.
Speaker:And they're like, these are all thyroid.
Speaker:What are you talking about?
Speaker:I'm like, no, my thyroid's fine.
Speaker:They're like, no, it's not like you.
Speaker:Every symptom here is is very clear.
Speaker:But again, back to this space of.
Speaker:There's so much here for us to unravel and unpack and like now, years later,
Speaker:right, of understanding this, of understanding how to be in my body.
Speaker:I'm a completely different kind of healer.
Speaker:The way that I take care of my body is so different the way that I take care of my
Speaker:Hashimoto's, like I have found it is less about medication and less about allopathic
Speaker:care and much more about how I care for myself from a very, like, base level.
Speaker:Um, it's, it's very different and it's the only thing that's been effective for me.
Speaker:Kelly Higdon (She/They): Yeah, and I think if you were in more.
Speaker:Ingrained in the system, right, with insurance and things like that.
Speaker:Then you have to up the ante in terms of what it means to
Speaker:create support for yourself.
Speaker:And again, in our book we talk about like, it's not about bubble
Speaker:baths and things like that.
Speaker:It's about really creating community, you know, getting actual people in
Speaker:your life, relationships, support.
Speaker:Having, being well resourced internally and externally to navigate that
Speaker:standing in the gap's not going to work.
Speaker:If you need, if you're in this place right now where you're working with
Speaker:insurance and that's where you're at, and maybe you're working your way out of it,
Speaker:you know, how do you resource yourself?
Speaker:And I think in my own learning and my own, like working with other kind of, you
Speaker:know, hiring coaches and stuff around.
Speaker:You know, divesting and, um, kind of undoing a lot of the.
Speaker:Capitalism, colonization and things like this.
Speaker:Really understanding, like indigenous wisdom.
Speaker:It's been around forever.
Speaker:You know, they really understood the importance of a, a system that's holistic,
Speaker:that supports, that's abundant in shares.
Speaker:I think that that's what we need more in our field, and that's what I hope
Speaker:that we are contributing to is the, the sharing out of our own abundance,
Speaker:sharing our knowledge, sharing like what we can to support other people
Speaker:in this industry and really kind of lifting all of each other up.
Speaker:You know, we need each other, we need people, we don't need corporations.
Speaker:Um, so, and, but in order to make it through.
Speaker:To create something that is actually healing to our nervous system.
Speaker:We don't do that in isolation and alone.
Speaker:Miranda Palmer (She/Her): Yeah.
Speaker:I think that's one of the things that, like we have, we've spent our whole like
Speaker:career at Zmi, um, recording podcasts, doing live webinars, bringing people
Speaker:together, having these conversations.
Speaker:We have.
Speaker:More free resources on our website than any other private coast you'll find.
Speaker:Um, and a lot of people will say it's not really great for business,
Speaker:but for us, we want to provide as much accessibility as we can while
Speaker:also marketing our, our program.
Speaker:Because that's also how, like, what pays for us to be able to, to give back, right?
Speaker:Like what is the balance of.
Speaker:Us being able to have something that's sustainable as a business as well as
Speaker:something that really gives back to our communities and that we can just be a
Speaker:light in the span of a lot of darkness.
Speaker:And I think, I think there are a lot of therapists too in their.
Speaker:Going to treatment for their depression or their anxiety with
Speaker:other therapists where they're going with a really well-meaning therapist
Speaker:that maybe is in the same scenario.
Speaker:That's kind of burnt out too.
Speaker:And then that therapist is going to another therapist
Speaker:that's in the same scenario.
Speaker:That's kind of burnout too, and sometimes like you're in it.
Speaker:Like you're in it so deeply.
Speaker:You don't know what you don't know.
Speaker:You can't see what you can't see.
Speaker:And even when a therapist, like we've had a lot of therapists over
Speaker:the years who have said, oh my gosh, I talked to my therapist about.
Speaker:Divesting from insurance and saying this, this just isn't sustainable for me.
Speaker:I'm gonna leave insurance.
Speaker:And the therapist was trying to talk them out of it,
Speaker:Kelly Higdon (She/They): oh my God.
Speaker:And
Speaker:Miranda Palmer (She/Her): saying, oh my gosh.
Speaker:You know you're going to, to keep people from being accessible.
Speaker:You know, you really can't do that.
Speaker:It's not possible now.
Speaker:I wanna share like a quick story regarding that.
Speaker:When I started my private practice during the recession in one of the top five worst
Speaker:cities to live in, in the country, we had double digit unemployment rates, right?
Speaker:We were the least educated.
Speaker:Uh, what was it like?
Speaker:We were the, the fattest, the most unhappy, the de most
Speaker:depressed organ, you know.
Speaker:City.
Speaker:We kept making these top five lists.
Speaker:I was like, do we have like public relations in reverse?
Speaker:Like what is happening right now in this city that I'm living in?
Speaker:But I lived there and when I started, people were like.
Speaker:There's no way that you can do this private pay.
Speaker:But also, I hadn't been licensed for two years, so they also told me, well,
Speaker:you can't get on any credentials.
Speaker:You can't get any insurance provider list because you have to be licensed
Speaker:for at least two years independently.
Speaker:So it was this, you can't do it.
Speaker:But there isn't an alternative and I didn't really have
Speaker:an option realistically.
Speaker:Um, so I thought, well, I'm gonna do this for two years or for a year and
Speaker:a half or however long it was gonna take me to, to get to that moment.
Speaker:Um, and I tell you what people were absolute, and, and I had people who
Speaker:really respected me as a clinician say, I will not refer to you
Speaker:until you are on insurance panels.
Speaker:People that I loved who, like, who I really respected them and who
Speaker:really respected me clinically were like, I don't believe in providing
Speaker:this without insurance care.
Speaker:Like this is a no brainer.
Speaker:Now, to me that makes sense.
Speaker:If insurance pays well, like pays a sustainable wage, and
Speaker:if insurance is available to everyone and it's not a for-profit.
Speaker:Scenario, but that's not the case that we're living in.
Speaker:But did I pr create a private pay practice with a waiting list?
Speaker:I was constantly full and I would get great outcomes with people and
Speaker:they would refer their friends.
Speaker:Like that's what happened.
Speaker:And I still at that point, the amount that I needed to charge to, to do
Speaker:good work and to do trauma work in particular, even with my crazy hours that
Speaker:I probably shouldn't have been doing.
Speaker:Um.
Speaker:The amount that I charged then in 2007, 2008, is more than a lot of therapists
Speaker:are charging right now, 15 years later, 16 years later is wild to me is wild.
Speaker:Hmm.
Speaker:Kelly Higdon (She/They): Well.
Speaker:I think how you do insurance contracts is going to be changing and people
Speaker:are gonna be looking, and corporations are gonna be looking more at patient
Speaker:reported outcomes, how well they're engaging in treatment and what you
Speaker:save them or cost them as the provider.
Speaker:The risk is going to be more and more on us.
Speaker:So how do we scoot out from underneath that and looking at how do we
Speaker:create systems that sustain us?
Speaker:To help us heal from what we've all been through and take better care
Speaker:of us and our clients and get them the outcomes that they deserve.
Speaker:Um, not from a place of pressure, but from a place of, of inner knowing and
Speaker:strength and integrity and our work.
Speaker:Miranda Palmer (She/Her): What are some of the, can we talk a little
Speaker:bit about some of the stats that we think therapists should be tracking?
Speaker:Um, 'cause we talk about this a lot in business school, like,
Speaker:what does this really mean?
Speaker:And I, I will throw out the stats that I think are most, um, impactful.
Speaker:And these are actually like, connected in with what the research says.
Speaker:Um, and one of those things is.
Speaker:Looking at our people coming in consistently, um, on weekly care.
Speaker:So many clients wait a really long time after knowing that there's a problem
Speaker:before they come in for care and they're needing to make a shift quickly.
Speaker:So having someone come in every two to six weeks, um, that doesn't
Speaker:generally lead to great outcomes quickly in the way that clients need.
Speaker:And when I have asked therapists for years.
Speaker:This particular question, I've gotten the same answer about 95% of therapists.
Speaker:There's like this little 5% group that's different, but 95% of
Speaker:therapists, if I say if you had two clients equal things, one person comes
Speaker:in 12 sessions every single week.
Speaker:The other person comes in 12 sessions once or twice a month,
Speaker:which gets better outcomes.
Speaker:95% of therapists say it's a weekly person every single time.
Speaker:So.
Speaker:How many people are you, are you actually holding to, this is the
Speaker:treatment plan that will work.
Speaker:So that's number one.
Speaker:Second piece is, um, what are you tracking in terms of mutual terminations?
Speaker:Meaning are you actually getting to the end of therapy where you guys
Speaker:are saying goodbye along the way?
Speaker:Right.
Speaker:And then also outcomes, conversations like, are you actually tracking
Speaker:and checking in with your client briefly at the end of end, end and or
Speaker:beginning of every single session as well as every four to six weeks are
Speaker:you diving into ask clients questions and adjust therapy along the way?
Speaker:I think and, and then I think finally your.
Speaker:Average number of sessions, do you actually know how long it takes
Speaker:if you have a mutual termination?
Speaker:For somebody to get to a point of saying, wow, therapy really
Speaker:worked and I'm ready to graduate.
Speaker:If you think their clients really wanna be in therapy every week for
Speaker:the rest of your life, of their life, that's actually not true.
Speaker:A lot of clients have much better things to do than come to therapy.
Speaker:So like what needs to happen?
Speaker:Are you someone who you're doing the kind of work where it takes
Speaker:36 sessions because you're doing.
Speaker:Really deep work on panic attacks or what have you.
Speaker:Is it 12 sessions?
Speaker:Are you doing chronic PTSD where it's closer to two years?
Speaker:Like what does that really look like to get people to mutual termination?
Speaker:And are you able to then take those numbers and use them
Speaker:to direct what you're doing?
Speaker:I, we, I had a conversation with a client yesterday, a, a coaching client yesterday,
Speaker:and they said, you know what, when I'm looking at my outcomes, I'm realizing my
Speaker:mutual termination rate isn't very high.
Speaker:People just seem to kind of drop out at different places, and I've
Speaker:realized that I really need to.
Speaker:Understand how to do terminations like this feels really vulnerable,
Speaker:but I can see from these numbers that I need to figure this out some more.
Speaker:And so we're teaching them about like how to do that and they're like, oh,
Speaker:this is the part that I was missing because we we're not taught these
Speaker:things and our, and our internships or in agencies or through insurance.
Speaker:Kelly Higdon (She/They): It allows for better informed consent, which then
Speaker:also allows for better clinical outcomes because we are informing our clients.
Speaker:So for example, we had a coaching client who did a very specific kind of therapy
Speaker:that was a limited number of sessions, but notice that by like number five, people
Speaker:were dropping out and not coming back.
Speaker:It was just like the normal, 'cause it, it was like there was some curriculum and
Speaker:some process that followed this order.
Speaker:It was court ordered treatment and things like that.
Speaker:So knowing that then they could change their consult script.
Speaker:They could change what they're doing in session saying, remember, usually
Speaker:at five people wanna quit and throw in the town and be like, I'm done.
Speaker:But if we can get past five, we can get all the way to the end of 10.
Speaker:Then we are gonna see like some serious transformation
Speaker:here and preparing that client.
Speaker:And sure enough, on session five, they'd be like, I'm done.
Speaker:Remember we talked about this.
Speaker:And then the client would stick.
Speaker:So she went from like 50% retention to like 90% retention.
Speaker:Why?
Speaker:Because, and then clients got the outcomes that they were coming in for.
Speaker:So it's this, it's not just, you know, um.
Speaker:It's a, it's attunement.
Speaker:Attunement is informed consent, like it all kind of feeds into each other.
Speaker:And can you imagine how you feel knowing and being really clear about
Speaker:like, this is how I work, this is how I get great outcomes there.
Speaker:There's much more confidence in that, and our clients feel
Speaker:that in our attunement as well.
Speaker:If we are unsure of how to say goodbye, are we unsure if this is even working?
Speaker:How do you think they feel?
Speaker:You know, it's not great.
Speaker:Yeah.
Speaker:Miranda Palmer (She/Her): And then that when we're talking about
Speaker:negotiating with insurance companies, if there's contracts you'd really like
Speaker:to stay on, to be able to say, Hey.
Speaker:I know my outcomes and I knew I do great work.
Speaker:I'm seeing this, many of your clients, my average number of sessions is this.
Speaker:This is the amount of people that get to high termination, mutual termination.
Speaker:This is what these rates look like.
Speaker:And again, depending on the kind of work you're doing, there
Speaker:might be different metrics Yeah.
Speaker:That you're using.
Speaker:But to be able to look at that from a grand, a grand scheme of things
Speaker:and say, look, I do really great work and maybe even I'm the only.
Speaker:Female or queer provider in a 50 mile radius, or that's doing this
Speaker:kind of work that actually has space available, whatever the dynamics are,
Speaker:to be able to have those kinds of conversations, those requests for raises.
Speaker:Are much more likely to be met with an actual raise than just
Speaker:saying, Hey, like a raise.
Speaker:Kelly Higdon (She/They): Or even if you're private pay, being able to tell a
Speaker:client, you know, look, I track outcomes.
Speaker:This is very important to me.
Speaker:I'm not interested in you coming here just to vent and then
Speaker:leave not feeling different.
Speaker:And so what I notice is that most people stay with me this long.
Speaker:This is what you can expect beyond the GFE good faith estimate and
Speaker:all that stuff we have to do.
Speaker:This is about really empowering clients to know what they're getting into and
Speaker:co-creating something that is successful and feels good for both of you.
Speaker:I just love that, right?
Speaker:And.
Speaker:In the insurance company, they make it sound like it's for both
Speaker:of you, but really it's for them.
Speaker:But in this situation where you're tracking your outcomes and you
Speaker:really know what markers are for good clinical care, it's, it changes the
Speaker:entire dynamic from your marketing to your attunement, to your processes.
Speaker:Miranda Palmer (She/Her): Yeah.
Speaker:I'm, I'm pulling up one of our clients that, um, that has had waiting lists.
Speaker:Off and on, depending on what the dynamic is.
Speaker:Um, they've been able to expand to a pretty, um, good size, I would
Speaker:say, medium sized group practice.
Speaker:Um, and they were able to say, Hey, here's why we think we're the best.
Speaker:Therapists in Orlando for working with trauma.
Speaker:On average, our clients compete therapy in five to six months.
Speaker:That means that in much less than a year, our clients are graduating
Speaker:from therapy with reduced or alleviated anxiety and PTSD symptoms.
Speaker:We track our client's progress beginning from the very first
Speaker:session to ensure you're getting the results you desire and deserve.
Speaker:Do you understand how.
Speaker:Much more powerful that is than saying, well, you know, every client is different.
Speaker:And, and that's true, right?
Speaker:Every client is different, but every client is different.
Speaker:I can't really tell you how long it's going to take, um, or what's going
Speaker:to happen to be able to say, Hey, on average it's five to six months.
Speaker:Can you commit to that?
Speaker:Does that feel good to you?
Speaker:What does this look like and like we actually care if you're getting better.
Speaker:It isn't about butts in the seat, it isn't about churn and burn it
Speaker:actually like we really deeply care about making sure that you have a
Speaker:great experience at our organization.
Speaker:And there are five star rated, like there's all these other spaces, but
Speaker:like what are we doing as therapists?
Speaker:Kelly Higdon (She/They): What does that do to your nervous system for those that
Speaker:are listening, like to consider this, if you haven't been doing outcomes care,
Speaker:or maybe you have been like, what does it feel like in your body to just kind
Speaker:of embody this idea, this concept of
Speaker:really speaking to the efficacy of you as a therapist like that?
Speaker:That's, it's good for you too.
Speaker:Like it's also, I hope I can just talking about it.
Speaker:I feel lighter, happier, excited.
Speaker:Like the energy pulls me forward.
Speaker:Like I can feel this pool, right?
Speaker:Like pay attention to those things.
Speaker:There's so much wisdom in here for you.
Speaker:I'm talking about in your body, you know, of like.
Speaker:We're talking about improving mental health care while taking
Speaker:care of ourselves as clinicians.
Speaker:And when you feel good about what you're doing, it's gonna
Speaker:make this work so much easier.
Speaker:It's just like, you know, smoother and,
Speaker:Miranda Palmer (She/Her): yeah.
Speaker:And I think there are some of you who are listening who feel a lot of anxiety
Speaker:right now thinking about this, and you're wondering like, well, what if
Speaker:I find out I'm not a good therapist?
Speaker:What if I find, what if I don't like the numbers?
Speaker:What do I do with that?
Speaker:And I think what I have found very consistently is that, again, 95, like
Speaker:most therapists, when they look at these numbers, just by looking at it.
Speaker:They find that the numbers start to improve over time.
Speaker:Just the act of being present with it and they actually find
Speaker:that having some conversations.
Speaker:We have a training that we do, um, call like out, out, that comes
Speaker:with a script about how to have outcomes, conversations with clients.
Speaker:You can do it for free.
Speaker:It has a ce, um, on our website, but like.
Speaker:That whole process of therapists understanding what is and isn't working
Speaker:with their individual clients helps them to do more of what's working and
Speaker:less of what's not that conversation that happens for a lot of clients.
Speaker:Sometimes clients are so myopic.
Speaker:We're training them to say, what do you wanna work on today?
Speaker:What's working?
Speaker:What's or, or not?
Speaker:What?
Speaker:What's working today?
Speaker:What's the problem today that they're coming in and
Speaker:just discussing symptomology.
Speaker:And while you even may be seeing the progress that they're making,
Speaker:they may not actually be seeing it.
Speaker:Or maybe you are only seeing sort of the negative part and you're
Speaker:not seeing any progress, but they're seeing progress at home.
Speaker:I mean, how many of us, I've heard this from therapists and I, I don't
Speaker:know why this person keeps coming in.
Speaker:Like it seems like they're still stuck and then they'll have this
Speaker:outcomes conversation be like, oh, they actually don't know how
Speaker:to verbalize what's going well.
Speaker:I didn't ask them the question.
Speaker:Maybe they didn't even notice what was going well, but when we took.
Speaker:A broader lens and we compared to where they started at and where
Speaker:they are today, they have made.
Speaker:Huge progress, but they couldn't even note it.
Speaker:And this can be a specific thing.
Speaker:How many of us work with trauma?
Speaker:Trauma in particular often cuts us off from being able to notice and
Speaker:celebrate the positives in our life.
Speaker:To be able to see the light at the end of the tunnel, to even see the idea
Speaker:that we could graduate from therapy.
Speaker:That's something that trauma can cut off and this can be an intervention as well.
Speaker:Like there's so much.
Speaker:Like juiciness in here.
Speaker:And I think many of us, like if we don't know from like a soul
Speaker:spirit perspective, that what we're doing is making a difference.
Speaker:I think that is like just like an energetic, like ugh, right?
Speaker:Like if you're just doing this work and you're just seeing the next
Speaker:client and the next client and the next client and you don't, you can't
Speaker:really like see and feel the progress.
Speaker:I think that is a recipe for burnout in this really difficult work.
Speaker:Kelly Higdon (She/They): And I don't wanna let an insurance
Speaker:company dictate what they, I don't wanna give them the visual of me.
Speaker:I wanna hold what I, you know, I wanna be the one that sees me.
Speaker:I don't want the insurance company to dictate what is worth being seen in me.
Speaker:So taking the power back again, our own sovereignty in this process.
Speaker:Well, we've covered a lot per usual.
Speaker:This is kind of fun.
Speaker:Um, but let us know what y'all think.
Speaker:Uh, again, we love reviews.
Speaker:It gives us feedback, right?
Speaker:Yeah.
Speaker:So that we can improve and shift things.
Speaker:This is just a new little addition to the podcast that we're, we feel like
Speaker:is really important right now with the times that we're in to, to talk
Speaker:unscripted, unfiltered about, um, the state of mental health care in our world.
Speaker:And we're here to support you through the ups and downs of it all.
Speaker:So.
Speaker:Thanks for doing this, Miranda.
Speaker:Thank you.
Speaker:Till next time y'all.
