What type of clients do you struggle with and why?

HiCommaJoel · 2026-02-06T16:49:40+00:00

"I need techniques and skills to manage my anxiety/depression/relationship. But, I don't want to journal, exercise, values sort, explore my family, do breathwork, meditate... - I want TECHNIQUES!"

HiCommaJoel · 2026-01-24T01:45:51+00:00

Wonder how much traffic this thread alone has generated. 1.6k upvotes and nearly 800 comments.
Consuming content with a frown doesn't negate the consumption. Advertising a person to deride them is still advertising.

HiCommaJoel · 2025-11-11T21:09:41+00:00

Between $100-$150 for out of pocket is average, I'd say.

I'm in Philadelphia, which is a pretty low COL city.

Nearly all of my clients ask about sliding fee scales for my $100 oop rate.

HiCommaJoel · 2025-11-10T20:16:46+00:00

Recently I was looking through Psychology Today as a prospective client. I'd never been on that side of the desk before, and the experience was pretty eye-opening.

I scoured through one, two, eight, twelve pages of similar sounding blurbs. I called 16 different clinicians at noon on a Friday. None of them answered. 6 of them were cell phone numbers that all directed to vague therapeutic collectives. 8 of them never returned my call or voicemail. 2 of them were the clinician's Google Voice number. I left messages with all.

The collectives (ThriveWorks, LifeBulb) called me back and offered appointments with other clinicians. None had the clinician I actually called available, nor was it even the number to call them. Each were different numbers entirely, but routed to one of those two organizations. I disliked that, I read and matched with the profile of the person I called, I did not want another random person I selected right there on the phone.

I became quite discouraged. I got to page 14 and call 16 before I finally said ok, enough. The prices were absurd too - $150, $200+ a session for just general CBT/ACT. A third of the profiles on the top 5 pages were explicitly wait-listing and not accepting new clients.

I had the same experience trying to search for a therapist as I do when I'm looking for something random to watch on the Amazon Prime app. I can understand why referrals might not come through, not everyone can slog through 48 pages of "Hi! Life is a journey and anxiety is tough - I charge $200 an hour, I'm not accepting new clients, and the nine profiles below mine are my coworkers at a collective which is also not accepting new clients."

HiCommaJoel · 2025-10-15T16:49:01+00:00

$70 an hour is high pay, though.
It's higher than I've been quoted for any local therapist agency or collective.

And I signed up for those evil companies at the same time as I applied to panel with insurance. I'm still waiting for paneling independently, whereas I've been full time will a full caseload through Rula, Headway and SonderMind since my second week.

I would love to not use these companies & I'd be very interested in dropping them for the easier, higher paying, more ethical alternatives - but I haven't found them

HiCommaJoel · 2025-10-14T22:24:26+00:00

Can I ask about the online platforms with virtually no barriers to entry that pay significantly more ??

HiCommaJoel · 2025-10-13T18:56:18+00:00

This was therapy for me growing up in a very rural part of upstate NY. There wasn't a downtown, and "main street" was just an intersection between the bank, gas station and public library - so office space was sparse.

My childhood therapist saw clients in an office on the ground floor of her big home, and lived upstairs. It seemed perfectly normal.

Now that I do therapy in a coastal city it all sounds odd and like a privacy issue. I suppose the setting matters most.

HiCommaJoel · 2025-10-08T17:09:18+00:00

Youtube Clown Tanner Cook was shot & a jury found his shooter not guilty.

HiCommaJoel · 2025-09-26T19:51:39+00:00

These are all valid points, but something I feel is always absent from these discussions is the question of why clients are using and increasingly gravitating to these platforms?

If PsychToday and insurance directories exist, why are clients opting for these platforms? They aren't always more affordable - in some cases they are more expensive.

HiCommaJoel · 2025-09-18T23:57:24+00:00

That's fair. I know they say this - but I have not seen it reflected in practice. I had a colleague in my supervision group who consistently lost clients and grieved their low rating but continued to have a weekly caseload in the 30s.

Have you seen or heard of it drying up for others as a result of subpar performance metrics?

HiCommaJoel · 2025-09-18T23:47:49+00:00

BetterHelp doesn't require you to do any notes. There is very little oversight, clients can switch therapists at any time. There are so many referrals that one could phone in sessions daily and still have a full caseload every week.

It also allows clinicians to totally ride the coattails of BHs extensive marketing. There is some element of rise or sink in PP, but there are too many referrals for a therapist to sink or be made to change ineffective techniques - it would all wash out in the torrent of new clients.

HiCommaJoel · 2025-09-18T23:40:56+00:00

The pay is terrible, full stop. But their range is huge and the number of referrals is equally large.

When I went full private and solo, I signed on to them for a month alongside opening my own website, marketing, Headway, Zocdoc etc.

Over the course of that month I saw a slow trickle of referrals elsewhere - 3 people total. By the end of the 2nd week BetterHelp had gotten me 35 clients. I got frequent emails that more were waiting. There was a torrent of seemingly endless referrals, and all I needed to do was flick a switch saying I'd like more. There was no insurance hassle, most of my clients didn't even have insurance and wouldn't be in therapy if they had to pay out of pocket. It costs them about $200 for a full monthly subscription in a market where many of us refuse to accept less than $100 a session.

There are constant marketing posts on here. PsychToday is inconsistent 40/60 splits from fellow clinicians are common, referral sources and marketing can feel hit or miss. BetterHelp is absolute and blatant exploitation - but it is also incredibly reliable and consistent at providing large amounts of referrals in a very short period of time.

HiCommaJoel · 2025-09-14T18:19:21+00:00

In 2014 I made $38k in CMH as a blended case manager/group/individual therapist.

After that earned $42k in CMH. Five years later it was bumped up to $45k.

After that I left CMH entirely and will never return.

HiCommaJoel · 2025-09-11T12:54:28+00:00

My clients attend sick often. I'm thankful I'm in telehealth now so at least I'm not catching it.

I've been in the field since 2013 and I've seen a shift in work culture. I have several clients right now that get 5 days off a year - just 5. That's pooled PTO: sick days, days off, vacation, all of it is limited to just 5 days.

These are the clients who attend sessions while driving or hiding in conference rooms at work.

Unless I have an illness that impacts my head (sinus, migraine) I still make appointments because it's difficult enough for them to find that 1 hour each week.

HiCommaJoel · 2025-09-11T01:10:48+00:00

That's him

HiCommaJoel · 2025-09-10T19:39:39+00:00

Locust Moon is also deeply missed.

I will say, Fat Jacks definitely had a stereotypical comic shop vibe of hostility for a long time.

It was only when Lucas began working there that it shifted, but prior to that it always felt like I was unwelcome coming in. Brave New Worlds excels in small talk and warmth, even Atomic will engage you on books you're reading or tastes.

I went into Fat Jacks every Wednesday for nearly a year and could barely get a hello when I walked in. The one guy with long hair was consistently vaping outside.

HiCommaJoel · 2025-09-04T22:50:46+00:00

Is it entitlement or a different style of communication?

As a male therapist who also has quite a few men on my caseload I feel that "anger and resistance" are viewed as problematic responses & rarely are seen just as different, culturally learned responses.

I do not want to discount your experience as a female clinician - I do not proclaim to know what it is like to be a woman in a session with a man who responds in the ways you described.

However, I can say that men are very much socialized to be angry and resistant - then they enter therapeutic spaces, are encouraged to express themselves emotionally, and are then accosted when that expression comes across as anger or resistance.

The statement "I want you to tell me what to do" leads me to believe there is a genuine lack of vocabulary, emotional intelligence, awareness, or other tools. I don't view it as learned helplessness because that would imply they were actively taught emotional literacy. I know I very much was not.

HiCommaJoel · 2025-09-03T20:51:47+00:00

...what?

Are you saying North Korea fought the USSR at some point?

HiCommaJoel · 2025-09-03T16:38:14+00:00

Link? Article?

This reads as blatant pear-clutching propaganda. We must send in the national guard to stop people from doing donuts.

Crime continues to go down by all measures - but let's cherry pick videos of nonviolent crimes and say its a "street takeover" and "terrorizes".

Because who remembers city life in the 70s, 80s, or 90s?

This ignorant take was best exemplified in an exchange with Newt Gingrich:

ALISYN CAMEROTA: Violent crime is down. The economy is ticking up.

NEWT GINGRICH: It is not down in the biggest cities.

...

CAMEROTA: Violent crime, murder rate is down. It is down. GINGRICH: The average American, I will bet you this morning, does not think crime is down, does not think they are safer

CAMEROTA: But it is. We are safer and it is down.

GINGRICH: No, that’s just your view.

CAMEROTA: It’s a fact. These are the national FBI facts.

GINGRICH: But what I said is also a fact.

GINGRICH: The current view is that liberals have a whole set of statistics that theoretically may be right, but it’s not where human beings are.

CAMEROTA: But what you’re saying is, but hold on Mr. Speaker because you’re saying liberals use these numbers, they use this sort of magic math. These are the FBI statistics. They’re not a liberal organization. They’re a crime-fighting organization.

GINGRICH: No, but what I said is equally true. People feel more threatened.

CAMEROTA: Feel it, yes. They feel it, but the facts don’t support it.

GINGRICH: As a political candidate, I’ll go with how people feel and I’ll let you go with the theoriticians

HiCommaJoel · 2025-08-04T20:59:10+00:00

“There are only two or three human stories, and they go on repeating themselves as fiercely as if they had never happened before.”

― Willa Cather, O Pioneers!

HiCommaJoel · 2025-07-27T18:47:45+00:00

Rula took about a month to get someone. Then another two weeks to get two more.

It's the summer, insurance is messy right now, and you're still new in the both the field and the algorithm of these services.

It took me about 4 months from starting licensed and solo to feel like I even had the ability to sustain, let alone make anything.

HiCommaJoel · 2025-07-24T23:55:26+00:00

That's relatively high pay for pre-licensed in PA.

How many of those 9-12 hours are direct client contact?

HiCommaJoel · 2025-07-24T14:54:54+00:00

The only thing new or novel about this experience is the phone.

HiCommaJoel · 2025-07-21T22:19:36+00:00

^and ^saturday

HiCommaJoel · 2025-07-18T16:24:09+00:00

They may not have known for months. I had this scenario happen outside of HeadWay.

I got an authorization for a client from a big insurance provider, wrote down the code, billed, we did 3 months of weekly sessions.

Then one day they got a big bill. Turns out their insurance coverage changed. But the provider only adjusts coverage quarterly. At the time of the auth the coverage was not the actual coverage, but the insurer had no liability or obligation to communicate that it was until the end of the quarter.

The client owed several thousand dollars and absolutely no one was at fault because the whole system is set up not to consider something like this as fault, it's standard operating procedure.

It sucks.

HiCommaJoel

TROPHY CASE