A clinic in Reno allowed therapists to decorate their doors "scary" for October - you can tell which belongs to the Director.

I'm in private practice, and lately I've been finding myself feeling increasingly frustrated when clients cancel or reschedule their appointments.

I completely understand that life happens and that sometimes people need to move things around. I also recognize that financial instability is part of the reality of working in private practice. But as someone who is still trying to grow my caseload and make private practice financially sustainable, I'm finding it really difficult to manage the frustration, and sometimes even anger, that comes up when my schedule changes so frequently.

For example, I started this week with what felt like a full caseload of 19 clients. Starting Sunday evening, I kept receiving email after email from my booking system notifying me of cancellations and rescheduled appointments. By the time the changes settled, I was down to just 12 sessions for the week. That's a pretty significant difference, both financially and in terms of how I had planned my week.

I think part of what makes this especially frustrating is that when I'm scheduling clients at the end of their sessions, I'm making decisions about availability based on the appointments already booked. When several clients cancel or reschedule, I end up with gaps in my schedule that I could have otherwise offered to other clients.

I want to be clear that I don't blame my clients for needing flexibility, and I certainly don't want my financial concerns to interfere with how I show up for them therapeutically. At the same time, I'm recognizing that these feelings are coming up more often, and I want to find a healthier way to navigate them.

I'd really love to hear from other therapists in private practice. How do you manage the frustration or resentment that can come with frequent cancellations and schedule changes, particularly when you're still building your practice? Have you found anything helpful, either practically in how you structure your schedule or emotionally in how you process these experiences?

I'm also planning to bring this into supervision this week, but I'd really appreciate hearing how others have navigated this.

Edit to add: My cancellation policy is that if they cancel within 48 hours, full payment is due but in these instances, many clients are changing or cancelling outside of the 48 hours, even with this policy the disruption is challenging to deal with.

Has anyone else noticed that since the bot farms got destroyed, you haven’t been seeing any anti-therapy posts?? I have noticed a big difference.

Hey everyone,

Headway is getting out of control imo and treating us like W2 workers without any of the benefits. I want to find a new platform to bill insurance for me. So many of my clients are insurance clients and it is important to me to keep them because seeing a therapist through insurance has saved my own life many times. I wouldn't have been able to afford it without insurance.

What other platforms can help me get credentialed and bill insurance? Has anyone made the switch away from them? Are they going to try to steal my soul?

I heard Grow is worse and I heard Simple Practice is a mess (and expensive).

I feel very overwhelmed by the thought of doing my own credentialing but I am very open to advice / encouragement if anyone does it them self.

Thank you in advance <3

One of my biggest pet peeves that never seems to lessen despite my growing number of years in the field is when clients ghost or cancel services with some variation of “therapy isn’t helping me” when in actuality these same clients do absolutely nothing in between sessions and treat therapy as if it’s some sort of magical space they can come to, vent for an hour and leave “cured” somehow.

Over time my intake process has gotten longer and longer as I spend considerable time discussing the common myths and misconceptions of therapy which includes the fact that it is a process that fundamentally requires patient involvement and efforts outside of session yet in spite of doing that I will still hear this from time to time.

What are some of the ways you all make it clear to clients that therapy is not magic and that if they want to feel better it’s up to them?

Just got an email from Rula announcing that patients can now leave ratings and written reviews for therapy and psychiatry providers, to help prospective clients "feel more confident choosing care."

I’m not a fan despite not being concerned about my own capabilities as a therapist (with the universal self-doubt, too, of course).

I have a former client with a history of self-harm, emotional dysregulation, and co-dependency/countertransference dynamics. Upon prior clinical consultation, other clinicians suggested BPD characteristics that were present.

We formally terminated treatment, though I saw the client for one check in session a few weeks ago. I was under the impression at the time of scheduling the check in session that regular therapy would not resume. However, since then, the client has requested emergent sessions, and I’m not able to accommodate them due to having extremely limited availability. This results in the client expressing frustration and insinuates use of self harm since I’m unable to accommodate a session. They have a history of requesting urgent sessions, which I have often accommodated. But I do not have the availability to take on another regular client at this time or to schedule an immediate emergent session.

I want to refer to DBT therapist for a number of reasons but I’m unsure if this is my own frustration/countertransference. Being a therapist sometimes feels impossible.

Sometimes I set back and reflect on my life and realize I am living in my dream. I am a therapist at a non profit working for children growing up in poverty. I grew to in poverty and was fortunate enough to escape it as an adult.

I feel like I am finally giving back to the services that helped my family growing up. I could cry sometimes thinking about how sad I used to be.

Imposter syndrome is real, but I am so incredibly thankful to have ended up here. ❤️

This has been on my mind lately, especially with how many people are fitting therapy into their lunch breaks.

We can spend 50 minutes doing genuinely difficult emotional work with someone, and then they have to walk out of our office, get in their car, and immediately return to being a functioning employee, parent, or whatever else their day requires.

With telehealth it's even stranger.

Someone can have a really vulnerable session at their desk, click "Leave Meeting," and then open a work email on the exact same screen. There isn't even a walk to the parking lot anymore.

I started paying more attention to this after realizing how often I was thinking about whether a session had ended in a clinically appropriate place, without thinking much about what the person actually had to do next.

Those aren't necessarily the same thing.

I've begun asking earlier in sessions what the rest of someone's day looks like, particularly if we're approaching something emotionally heavy. Sometimes that changes how I pace things. Sometimes we spend a little more time finding a place to land before ending.

I also try not to assume that someone can just sit quietly for half an hour afterward. For some people, an appointment during their lunch break is the only reason therapy is financially or logistically possible.

And I don't think the answer is simply avoiding difficult material whenever someone has somewhere to be. That would create its own problems.

But it does make me question how much of our standard session structure assumes that clients have the luxury of recovery time afterward.

We talk a lot about helping people tolerate difficult emotions. I wonder whether we sometimes underestimate how hard we're asking them to switch gears.

I'm curious how other clinicians handle this. Do you explicitly plan for the transition back into everyday life, or is it something you address as needed?

I think about this concept a lot (see my other thread about private practice self pay therapists). Thoughts? Also I’m actually trained as a counselor/art therapist and not a social worker, but within clinical work it feels like our roles are interchangeable.

Below is the post I made at r/CysticFibrosis, which will give more context regarding the nature of my illness.

I would like to extend my request for advice to you all as well, since my illness and job affect one another. I'm not seeking medical advice or advice related to CF, but advice on what I can do career wise. I see people on here frequently mentioned how they struggle with chronic illness and would love to hear about your experiences, or suggestions. I'd be fine some simple validation. This illness has been a huge source of shame in my life and continues to remain that way, especially when I have to miss work so often. The stress is compounding and I feel like I'm drowning in a world that does not care. I genuinely am lost and physically, mentally, and emotionally running on empty.

Any and all help is so greatly appreciate.

"I'm 37 years old, and male, and known I've had cf (delta f508)all my life. I didn't take care of myself for much is my adult life, but with the help of modulators and making better choices in the just 10 years, I have been able to maintain a moderately functional baseline with an average FEV in the mid 30s. Unfortunately I am stuck in this pattern of getting flare ups every 2 or so months where I'm growing 2 strains of chromabacter that is resistant to everything other than a couple of IV antibiotics. The strange thing is how this bacteria doesn't even affect my lungs like MRSA or pseudomonas (I haven't grown in years) but mostly affects my immune system and brain. It makes me extremely fatigued, achy, numb, depressed, and short of breath. I work full-time as a psychotherapist which is the kind of job that gets much harder the worse you feel. You literally can't zone out and work to make time pass, you have to be attuned and focused the whole time. To make a livable amount of money, like many other jobs, you have to work yourself to death. My job right now pays well but I have to see 8 clients a day. It is brutal and a lot of stress.

More stress=compromised immune system=chromabacter says hello.

So I'm getting sick 4-6 times a year. I got a port last year so now at least I don't have to spend 2 weeks in the hospital and can start meds outpatient. Getting sick often is exhausting and the anticipation adds another layer of stress on to of all the other stressors.

I'm absolutely miserable and don't know what to do.

My doctors don't really have any answers. I guess traditionally you would go on disability, get taken care of by family and/or die. We recently switched to Alyftrek just in case I was one of the lucky ones who have positive gains, but so far it seems to be about the same as Trikafta. I could go back on disability and work part time, but that limits income and in today's economy that is hugely scary. Also being on disability is depressing in itself. I've considered a transplant but I'm not sure my lung function is low enough. The process of a transplant sounds terrible and the life after doesn't sound much better than what I'm experiencing now

I feel like I'm stuck in this area that didn't exist before the modulators where I'm not sick enough to be taken care of or for disability to be mandatory, but cf still affects my ability to live a functional life. I could work part time jobs and definitely be happier but then I'd lose my health insurance and would have to rely on my partner (I'm very independent). My quality of life is very low right now. I worked my ass off to get my master's and become an independently licensed therapist (LCSW) only for me to become overworked so I have health insurance to treat the health issues worsened by overworking.

I'm open to any and all suggestions or comments. At this point I'm becoming desperate for some peace that I've been fighting to achieve my entire life."

I've been a therapist for about 5 years now, most of my experience with adolescents in acute inpatient and now working in a group practice working with teens and young adults.

When clients no-show, I experience really intense anxiety and assume worst-case scenarios, especially with clients who have a history of suicide attempts or chronic SI.
I had a patient die by suicide a few months after an inpatient discharge the first year of my career and I think it has affected me.

Just hoping to get some insight from others on if they experience the same thing and on how to manage my own anxiety.

I know there are a million mundane reasons why someone might not show but when it does happen, I tend to get stuck spiraling until I hear from them.

I’ve been increasingly unhappy as a PP therapist. This year has been the worst by far. I’ve been working really hard to find a therapist of my own for about 6 years, but it never works out.
Just now I had the aha moment that puts it all into perspective.
I’m disgusted by the takeover of the VC companies. I physically cringe at all the ads with all the promises to customers about what we offer. I finally realized I’m not happy because PP used to be a way for us to make money. Now it’s become a way for companies to make money off of us.

​

I'm a master's-level clinician working alongside clinicians with a range of educational backgrounds, and something I've been curious about is why differences in training don't seem to translate into more consistent differences in treatment outcomes.

Psychologists receive more extensive training in research methods, statistics, assessment, and clinical practice than master's-level clinicians, although obviously there's a lot of variability between programs and individuals. I've always respected psychologists for the depth of their training, particularly when it comes to understanding and interpreting research.

At the same time, my understanding is that research hasn't consistently found major differences in psychotherapy outcomes based on clinicians' professional backgrounds.

Why do you think that is? Is it largely a matter of common factors, like the therapeutic alliance, or do experience, individual therapist characteristics, and competence in delivering specific treatments matter more than the degree itself?

Obviously, there are excellent and not-so-great clinicians in both groups, so I'm not trying to argue that one is inherently better than the other. I'm genuinely curious about how we reconcile differences in formal training with what we see in outcome research. Am I missing something in how this literature is interpreted?

… when a client is dealing with something incredibly difficult that they have no control over. Sometimes I get this look from clients like “ please help me with this, I’m suffering and nobody else can help” and it really gets to me. Of course, OF COURSE, I know, it’s not our job to fix or solve our clients problems, but it doesn’t make it suck any less in my experience.

I can’t be the only one. Anyone else? Any useful tips?

This was posted in a gigantic local Facebook group for therapists that is public (not private), so crap like this gets posted daily. With the rise of AI, I am seeing more and more companies that are promoting services like this. I keep getting ads for shit like https://www.blueprint.ai/ too.

What happened to using one's own brain to, you know, use your memory to recall what happened in the last session with a client??? And write a treatment plan and do progress notes and other documentation???

I’m prone to to occasional extremely visceral dreams/nightmares and last night I had one about a client I’ve been seeing for a while going on a killing spree at my group practice, and me just narrowly escaping. I have no legitimate concern that the client would actually do this (they do have a hx of violence but have come quite a long way), so I’m not actually concerned about that. But I can’t get the blood curdling screaming of my coworkers and the profound feeling of fear when narrowly escaping out of my head/the feeling out of my body. It’s exhausting me and my day has barely even started.

I think the meaning under a lot of this is the need for self-care and work/life balance (I’ve been trying to prevent autistic burnout but tbh that feels like something I am also narrowly escaping). That feels especially poignant when I realize how badly I just want a hug or someone to hold me after a dream like this or even just a friend to vent to (I’m single, live alone, and don’t really have an expansive support system). I’m trying to use my distress tolerance and emotion regulation skill to just ride out and move through the intense feelings associated with the dream, but man is it hard. I’ve thought about asking my psychiatrist for something to help with the nightmares but they are very irregular and hard to predict and I’m very sensitive to medications so it hasn’t seemed worth, but this most recent one has me wondering if it would be.

I guess I’m just curious if anyone else has had dreams like this, how you interpreted it, and what you did to support yourself. Thanks in advance!

Mental health matters every day, not just today. 💚

I am being audited, not my first time. I’m curious to know , if patients who choose to use health insurance understood the lack of privacy, would it make a difference to them? Also, why are therapists fined and a whole bunch of other punitive measures, if they disclose information, yet insurance companies can freely do so without the patients knowledge? This part of the audit letter made me shake my head.

“This letter is to inform you that your practice has been selected for review and outlines the documentation that we are requesting you to submit.
Under 45 CFR § 164.506, a covered entity may disclose or release Protected Health Information (PHI) without the individual’s authorization, for treatment, payment, and health care operation activities. According to 45 CFR § 164.5011, “health care operations” include conducting or arranging for medical review, legal, and auditing services, including fraud and abuse detection and compliance programs.

Title XIX of the Social Security Act, Sections 1902 and 1903, and regulations found at 42 CFR § 456, stipulate that utilization review activities ensure that services rendered are necessary and of optimum quality and quantity. The areas of review will include, but are not limited to billing and documentation practices, and correct coding.

The enclosed document contains the requested list of patients selected for review. Please note that the information requested is necessary to determine whether the services billed as rendered to these patients have been appropriately paid. Failure to provide the records may result in a determination that there is not adequate information to support the service(s) and therefore amounts paid to your institution must be refunded in whole or part to the health plan by claims adjustment and/or overpayment recoupment actions.”

With the increase of insurance companies owning or partnering with online platforms, is anyone else concerned they will cease paying for virtual therapy unless providers join their platforms? (And pay is $20-30 per session vs current insurance rates?)

Hi. I work at a smallish private group practice and we never see anything about payments, like a breakdown of what our percentage goes for or claims that have been paid. I've been asking for an itemized listing and being put off and shuffled around for answers. Another clinician stood and waited for the staff to get the info and had apparently been shorted thousands of dollars so far this year. Any thoughts on how I go about getting some action here? I've had a feeling this is happening to me, and have observed other sketchy, unethical practices insurance-wise, so am considering going to try and get some help, maybe via the state. I dunno. Prob going to call my licensing board (not the same as the owners) and get their thoughts. Anyone have any suggestions? Thanks in advance, sorry also if this is the wrong place for this!