12 Signs You Work at an Exploitative Group Practice
15 minute read.
After celebrating my private practice’s 1st birthday, I felt ready to help other therapists who were feeling stuck, like I was a little over a year ago. With that, I added therapist coaching to my small selection of services.
My aim is to liberate the Exploited Therapist, or the therapist whose time, energy and labor has been exploited for profit. I also understand that many therapists may think there are no other options, just like I did. So, this list is for those individuals who may need a tiny push to take the next step to liberation.
What is a group practice?
For readers who don’t know, a group private practice is a business, typically owned by a therapist, with one or more therapists working under them. The owner of the group practice is usually responsible for advertising, payroll, managing the rented space, billing and other administrative, non-clinical tasks.
This means that the group practice owner will likely take a percentage of any money that therapists in their employ bring in. Sounds simple enough. You (the therapist) give a small amount of your pay in exchange for those services. Sure.
Many group private practices (PP’s) unfortunately take on the function of a mill, where dozens of therapists are hired, only to increase the amount of clients that can be seen. In a mill, health and well being of clients and therapists are not priority, profit is.
You may have read that and thought, “Duh, that is how a business makes money.” Let me be clear, I am all for making money. I am a millennial with more than $65,000 in student loan debt and have yet to own a home. I believe money absolutely brings a higher quality of life and happiness, and those who disagree have likely never lived without the safety net of financial security. Therapists should make good money.
The issue that comes into play is one of ethics. Therapists, social workers, and psychologists in the US have a strict code of ethics that speaks against providing faulty, unsafe care to clients. Exploitative group practices tend to violate these ethics time and time again, treating clients like dollar signs while exploiting the labor of therapists, who already work an emotionally cumbersome job.
Many group practices deny therapists the opportunity to make a desirable wage without sacrificing their health. During the summer of 2020, I was seeing 30-35 clients weekly, all while uprisings were happening in my city and my clients were deathly afraid of what the future was going to bring. I was burnt. out. Because I was unable to rest and recuperate effectively, I was in emotional and physical pain daily. I was unhappy, angry and terrified.
I decided that I was unwilling to continue investing in a group that was not interested in the care of their employees over profit. That and I finally started listening to my partner who had been saying the same thing for two years (high-fives for denial). I opened my own private practice in 2021, and it just celebrated its first birthday.
Thankfully, there are many group practices out there that are prioritizing the health, wellness and financial security of their therapists, while offering exemplary care to clients that are lucky enough to seek them out.
I compiled the list below based off of my own experiences with group PP, and that of my therapist colleagues and friends. For the benefit, and possible confusion of the reader, I will be using group PP owner, supervisor, boss and manager interchangeably. (This may speak to frustration I felt while writing this piece.)
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1. You’re working more hours than you committed.
Like many therapists starting off in PP, you start off part-time. You commit to working 5 clinical hours, or 5 clients, likely continuing to work your full-time job during the day.
As time goes on, maybe you are asked to take another client “just this once.” Maybe a referral has requested you, or maybe they fit perfectly into your niche. Cut to six months later, you may very well find yourself with 10+ clients and the gentle suggestions from management and admin have turned into thinly veiled shame for not taking on more.
2. Love bombing.
Love bombing is an exploitative, coercive tool used early on in relationships (romantic, group, occupational) in which the person/persons in power shower the newcomer with love, affection and attention.
The newcomer is typically in need of this positive attention due to lack of access to resources or inexperience, resulting in them becoming reliant on it.
Similarly, exploitative PPs often hire young, inexperienced therapists and praise them endlessly during their first few months of employment. This can quickly turn sour when you (the newcomer) ask for something that you need (reduced hours, better pay, more supervision) or make complaints (poor working conditions, long hours, lack of safety).
Exploitative bosses are known to withdraw this support, leaving you feeling rejected and unsure what they did wrong (spoiler alert: you did nothing wrong).
Love bombing new and/or young therapists is a manifestation of idealization, and we all know what follows that.
3. Supervision feels like therapy.
In addition to being analyzed when you bring up issues, supervision can often feel like therapy. Exploitative PPs have an unhealthy relationship with supervision. Your supervisor may hold a dual relationship with you, meaning they provide you with supervision and manage your employment (more on that later).
I have had many friends and colleagues tell me that on top of being overly analytic, their supervision felt judgmental, as if what they disclosed would be used against them later. Personally, I still cringe when I hear, “What does that bring up for you?“
Now, no therapist is perfect. Any seasoned supervisor will tell you that at times, it can be challenging to keep your supervision hat on when your supervisee clearly is in need of additional support.
But as we say to our clients, “That is just a thought.” When supervisors keep their boundary, fighting the inkling to “therapize” their supervisees, they are doing them a service.
4. “You are going to make so much money.”
Unfun fact: this is a lie fed to front-of-house restaurant employees as well. I know because I heard it there too.
What you aren’t told is that in order for this windfall of cash to come, you need to overwork, never have weekend plans, give subpar therapy because you are exhausted, while your relationships and other pieces of your personal life suffer.
5. Incentivized pay.
In the US, therapists are still missing the “Don’t take on more than you can” piece in our code of ethics. Thankfully, this is preached in a lot of therapy circles, where folx can come together and advocate, teach and grow with each other.
Sadly, it is absolutely not talked about in exploitative PPs. Incentivized pay lessens the compensation for therapists that work less hours, meaning their time is of less value if they take on less clients.
The process is so simple, yet deeply insidious as it punishes therapists for working less. One may argue that rewarding therapists for working more is a positive thing, which is what we call internalized capitalism, my friends. Or the idea that our moral fiber and value as a human being is based off of our income and how hard we work.
This is how it’s done: Want to work 20 clinical hours per week? That’s good, we will take 50% of your pay. Want to work 25? Great! We will only take 45%. Want to work 30? Oh my god, such a good employee! We will only take 40% of your pay. Want to see 40 people per week? Just to be clear, do you want to be responsible for the mental health and well being of FORTY people PER WEEK, while also writing all their progress notes, keeping in contact with other members of their treatment team, making reports as needed, monitoring symptoms and keeping up with emails?? So cool, we will only take 35% of your pay.
Remember earlier when I mentioned how my health was suffering during the beginning of the pandemic? This was around the time when the incentivized pay structure was offered to me (the first time). They truly thought they were doing me a favor.
I currently work no more than clinical 15 hours per week, and I get to keep all of the money I bring in. I am the best therapist I have ever been, and in my extra time, I market myself by writing fun blog posts about what I’ve learned. I am more happy, healthy and my personal life is filled with pleasurable activities and relationships.
You know what else is terrible about incentivized pay? BetterHelp uses it. You know, the BetterHelp that offers “accessible therapy“ by aggressively underpaying therapists and putting clients in danger by not having mandatory informed consent. That BetterHelp.
6. Your supervisor cuts your paychecks.
You know the type of supervisor that you dreamed of in grad school? The one that would urge you to use your benefits and take time off when you were feeling burnt out? The one who would lighten your caseload until you were feeling fully capable again? Yeah, a supervisor who cuts your paychecks will never be that person.
For this reason, as stated above, no dual relationships should ever exist in the therapy or supervision space. It is unethical for therapists to hold more than one relationship with a client as the power dynamic is impossible to uphold in every scenario, which brings about possible harm for the client. The same is true in supervision.
If your supervisor is making money off of your labor, telling you to take time off to recover from burn out will be way at the bottom of their list. This means they do not have your best interests at heart, no matter what they tell you.
7. You are “analyzed” when you bring up an issue.
Have an issue with management? A client? Your schedule? Many exploitative bosses who are therapists will weaponize their therapeutic skills and turn the issue back onto you.
They may suggest that you have made bad decisions, are weak, not trying hard enough, or you have your own stuff coming up.
Now, we all have stuff that comes up while giving therapy. But to suggest that every professional issue you have has to do with said stuff is manipulative, and distracts you from the issue, causing you to internalize it and blame yourself. I like to call this gaslighting.
8. Clients are not a “good fit.”
“Assignment by availability” occurs when a client has a specific time/day they are available, which is given priority over their actual needs. This only changes if the client requests a specific therapist or skill set.
A “bad fit” of therapist and client can present in many ways: a client not “clicking” with their therapist, the client not liking the therapist’s treatment style or unmanageable transference/counter transference that manifests both either in judgment, projection and all the other fun possibilities.
Again, let me be clear, there will always be good and bad fits in therapy. Obviously. We are all beautiful, intersectional human beings with different beliefs, identities, personalities and nuance. It is a client’s right to get treatment from a therapist they feel safe with, least of all click with.
Therapists are also allowed to ethically refer the client out if the fit is not good, if the client's presentation poses a personal challenge for the therapist, or other reasons.
To add to this, an exploitative group PP owner will not teach you how to refer out, nor will they encourage or even allow it. In case you don’t know (I didn’t know until starting my own PP), a therapist “refers out“ when they feel they are unable to ethically offer effective care to a client. This can happen for a number of normal reasons, including the client requesting it.
Point is, these exploitative bosses will see an outside referral as a loss of revenue, and frame it as a failure, forcing the therapist to continue treatment. This endangers the client and pushes the therapist one foot closer to burn out.
9. You are pushed out of your scope.
What is worse than a poor fit? An unsafe fit. This is another reason why assignment by availability jeopardizes the client’s safety: harm is caused to clients when therapists are not skilled in their areas of need.
For example, LMFT’s have training in treating couples and families, other therapists do not have that training their education (unless they attain a separate certification). Therefore, couples and family counseling should be left to them.
Some therapists specialize in treating age groups or conditions, like adolescents, children, substance abuse, psychosis, or trauma. Same as above, clients with those needs/from those age groups should be assigned to those therapists who know how to treat them.
10. Promises are broken, little follow through.
Whether it’s promises of better benefits, growth in the company or simply figuring out a clerical issue, one should always follow through, and if they know they won’t be able to, they should say so.
To be clear, rarely does an individual in a professional setting say, “I promise.” But if you give your word, or say that you are going to do something, it’s reasonable for the other individual to expect you are actually going to follow through.
Before I left my old job, I remember the first time I thought to myself, “You aren’t going to do anything about it” after a previous supervisor told me, for what felt like the 100th time, “I’ll follow up,” or “I’ll look into it,” or, “Don’t worry, I’ll take care of it.” This had been said to me with zero follow through enough times to result in me expecting nothing.
If you feel I’m being nit-picky here, that is fine. But I urge you to never underestimate the importance of your own time, the time of others and trusting someone’s word.
11. Coworkers who leave are trashed.
Remember earlier when I said that idealization always leads somewhere? Well here we are, devaluation. One of the first rules about relationships that we learn as adolescents and young adults is “pay attention to how they treat people after a relationship ends.” Or the time honored, “If everywhere smells like shit, check your shoes.”
Pay attention to how your boss, manager or supervisor talk about a therapist who leaves. Is the therapist “growing,” “moving on” and “finding their dream job”? Or are they “abandoning,” “ungrateful” and “too big for their britches”? Supervisors are supposed to nourish the growth of those under them, not stifle it.
12. No boundaries.
Many supervisors, bosses or managers in PP foster the toxic “we’re family” mindset. If you have not yet learned why this is a problematic way of thinking, let’s take a medium-deep dive.
“Family” work cultures foster poor boundaries (phone calls, texts, emails sent after hours with an expectation of immediate response), emotional reactivity/personalization when you bring up issues (ex, I can’t believe you have an issue, we treat you like family!), and a false need to remain “loyal” which hinders your professional and personal growth. The “we’re family” mindset is meant to keep you stuck, growing the wealth of whoever cuts your paycheck.
In closing, if you have ever been curious about the feelings of discontent and frustration you feel working in your group PP, this post is for you. I currently offer coaching services to exploited therapists, liberating them by helping them start their own private practices. (Read more about business coaching.)
As a close friend pointed out to me while reading this piece over, this is not just a private practice problem. This is a mental healthcare problem.
If you are a group practice owner and some of this describes you, I am calling on you to make immediate changes. After all, exploitation of labor is one of the favored tools of white supremacy and patriarchy. If you are contributing to the problem, find a way to immediately stop. Do not wait until you’ve “made it“, can sell the practice for a profit or until you’ve finished the addition to your house. Just stop.
Stay tuned for future posts about liberation oriented therapy, living mindfully and pleasurably, and calling out exploitative bosses.
Thank you for reading!
Email contact@teletherapywithsarah.com with questions/comments/love.
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Very Best,
—Sarah (she/her)
*Disclaimer - This piece was written by a straight, cis, able-bodied, white woman. Intersectionality (coined by lawyer, civil rights advocate, scholar and philosopher Kimberlé Crenshaw) tells us that race, ethnicity, class, sexuality, gender, etc. that differ from the above identifiers encounter hardship and oppression at a much higher rate.*
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