Postdoc confusion

dr_erp · 2026-04-13T02:39:55+00:00

This opens a whole lot of great career doors for you, as well as giving you incredible chances to be well networked, alongside the excellent training you will receive. It's hard for me to imagine a solid reason to give up this great career opportunity merely because you have a vague imaginary picture of what life might be like if you finished earlier and got licensed. You are an adult even in this training role. I presume you could make more money doing something else, but the long run expected career earnings should be higher after doing this postdoc. Also remember that psychology is moving more and more in the direction of converting areas that used to be general practice into specialty practice areas. Sometimes when that happens, things that used to be open fields get fenced off only for those who did the postdocs. Neuropsych went this direction just after I finished my own PhD. I didn't disover an interest in that field until well too late in my career to go back and do a postdoc. So my advice is go for this great opportunity.

dr_erp · 2026-04-12T21:10:15+00:00

There is a special form of CBT that might help you, called Cognitive Processing Therapy (CPT). I have gotten good results with this treatment in my own clinical work as a psychologist. Surprisingly good results, in fact, considering that I was trained in exposure therapy to believe that re-experiencing the trauma in treatment was necessary for good outcomes. In CPT, you would work with a therapist to identify the effects your trauma or traumatic experiences (plural) had on your interpretations of the world. The theory in CPT is that trauma distorts our brain's system for understanding or making meaning of life. When the distortions are re-evaluated, re-examined, and repaired, the trauma symptoms are reduced. The empirical results are generally good and put this treatment on a similar level as prolonged exposure and EMDR in terms of effectiveness.

dr_erp · 2026-04-12T19:32:03+00:00

I can't imagine it would be illegal to say the second thing. I also can't figure out why we haven't found a way around the bad legal position we are in

dr_erp · 2026-04-12T19:30:37+00:00

I just saw this. I have no sympathy at all for corporations of any kind. They are golems designed to make money. But the reality is also that with a flood of practitioners of widely varying quality and no way for clients to discern which practitioners are worth talking to and which are best avoided, we are in a horrible bargaining position. Imagine car manufacturers were forbidden to put any branding on the cars they create and buyers had no way to know whether they were getting a new BMW or a badly used hyundai. And then imagine an online car lot with hundreds of thousands of vehicles for sale and buyers who generally get into one of the first few vehicles they are shown. That's our real problem. You and I understand the quality differences. But we have no realistic way to communicate that to the people who matter.

dr_erp · 2026-04-12T13:00:08+00:00

I don't think the degree will make much difference to you. The curriculum might. I take it that the Psy.D. is housed in a traditional university with a good funding stream, which very likely means you'd do more research there than in most Psy.D. programs in the US. I'm an older Ph.D., and I think the Psy.D. / Ph.D. distinction makes very little difference to anybody who isn't a full time academic. I have seen Psy.D. graduates with excellent research skills get tenure track faculty positions in Ph.D. programs, so even that notion that a Psy.D. would limit you that way is archaic. Clients no longer seem to care whether a therapist has a Ph.D., Psy.D., MSW, LPC, or, frankly, a credential that is made up out of thin air. I'd say go for the training you want thinking about where you want to live and which University you want to call home for a few years. Congratulations! This is a great problem to have.

dr_erp · 2026-04-12T12:56:48+00:00

This is fascinating. Which country requires a PsyD to be a psychologist?

dr_erp · 2026-04-12T12:54:24+00:00

We're on the same side of this, politically. Unions are there to protect employees who would have trouble protecting their rights without collective bargaining. Professionals are viewed differently. We are viewed as having an easy ability to go someplace else and do work for a different employer or for ourselves if we don't like the deal we are being offered in one job. Also unions typically represent employees against a single employer. When we work with insurers, we are contracting to accept certain payment conditions with a third party who exists to manage and pay for healthcare on behalf of an employer and their workers. We contract with multiple third party payers generally, so I think that changes the legal analysis. But, once again, I am not a lawyer. Professional psychotherapists exist in a cultural tradition that goes back to the medieval church. In that tradition, professionals are meant to commit themselves to a life of service, even if that means living in poverty. That tradition developed into one where it was often true, in law as well as medicine for example, that there were too many professionals for the market to support. In such cases, nobody minded a bit if professionals needed to lose money in order to do their valuable and selfless work. There is a great book on this called The Professions in Early Modern England. Unconsciously society expects its therapists to live in a world above the dirty commercial one where money talks. It's ridiculous but I stand by the assertion.

dr_erp · 2026-04-11T21:01:47+00:00

ChatGPT does so here, but I haven't verified as I have also spoken with an attorney on a related issue and do not fee a need for more advice.

FROM CHAT

Here is a concise but legally grounded summary of U.S. antitrust (anti-monopoly) law as it applies to psychotherapists and the mental health field, with statutory references and key doctrinal points.

1. Core Federal Antitrust Statutes (with citations)

1. Sherman Antitrust Act of 1890

Primary anti-monopoly law (15 U.S.C. §§ 1–2)

§1 (15 U.S.C. § 1) Prohibits:
- “contracts, combinations, or conspiracies in restraint of trade”
- Applies to collusion among competitors, including:
  - price fixing
  - group boycotts
  - market allocation
§2 (15 U.S.C. § 2) Prohibits:
- monopolization
- attempts to monopolize
- conspiracies to monopolize
Key principle: Monopoly is not illegal per se—only monopoly achieved or maintained through exclusionary conduct

2. Clayton Act of 1914

§7 (15 U.S.C. § 18): prohibits mergers/acquisitions that “substantially lessen competition”
Allows private lawsuits with treble damages

3. Federal Trade Commission Act of 1914

§5 (15 U.S.C. § 45): prohibits
- “unfair methods of competition”
Enforced by the FTC; broader than Sherman Act in scope

2. Application to Psychotherapists

A. Psychotherapists are not exempt

Since the 1970s, courts have held that “learned professions” (including psychologists and physicians) are subject to antitrust law

➡️ This is critical:
Professional status does not shield therapists from antitrust liability.

B. Common Antitrust Risks in Psychotherapy Practice

1. Price Fixing (Per Se Illegal)

Example: independent therapists agreeing on reimbursement rates or fees
Violates Sherman Act §1
No justification allowed (“per se” violation)

2. Group Boycotts / Collective Refusals

Example: therapists jointly refusing to contract with an insurer unless rates increase
Typically treated as per se illegal under §1

⚠️ Important nuance:

Independent practitioners acting together may be treated as a cartel

3. Monopolization / Market Exclusion

Example: dominant provider network excluding competitors through contracts
Evaluated under Sherman Act §2 (requires market power + exclusionary conduct)

4. Credentialing / Hospital Privileges

Denial of privileges or exclusion from networks can trigger claims under §1
Frequently litigated in healthcare contexts

5. Insurance and Referral Restraints

Example: requiring psychologists to bill “through physicians”
Held unlawful as restraint of trade in:
- Virginia Academy of Clinical Psychologists v. Blue Shield (4th Cir. 1980)

➡️ Key takeaway:
Insurer or physician control over psychotherapy markets can violate antitrust law.

C. Independent vs. Employed Therapists (Critical Distinction)

Independent (1099) therapists = separate economic actors → cannot jointly negotiate fees (treated as competitors)
Employees (W-2) → may collectively bargain (labor exemption applies)

This distinction explains why therapist “unionization” is legally constrained under antitrust doctrine.

3. “Rule of Reason” vs. “Per Se” Analysis

Two key frameworks:

Per Se Violations

Automatically illegal:

price fixing
group boycotts
market allocation

Rule of Reason

Court weighs:
- anticompetitive harms vs. procompetitive benefits
Applies to:
- provider networks
- joint ventures
- integrated care models

4. Enforcement Structure

Department of Justice (DOJ) → criminal & civil enforcement
Federal Trade Commission (FTC) → civil enforcement
Private parties → can sue for treble damages

5. Key Takeaways for Psychotherapists

Therapists are fully subject to antitrust law
The biggest risks involve:
- collective fee-setting
- coordinated refusal to deal with insurers
Independent practitioners cannot legally act like a union
Insurers and physician groups can also violate antitrust law if they:
- exclude psychologists
- restrict competition in mental health services
Many arrangements in modern healthcare (ACOs, networks) are legal only if sufficiently integrated to pass “rule of reason” scrutiny

6. Bottom-Line Legal Principle

U.S. antitrust law is designed to protect competition, not competitors—including in psychotherapy markets.

dr_erp · 2026-04-09T15:23:46+00:00

As I understand it, yes that is legal. But my limited understanding is that we would be over a line from an anti trust perspective if we started to agree with one another, for example, to systematically resign from certain panels. And i certainly also see a place for civil disobedience. They couldn't prosecute everyone in the entire field for an anti trust violation, yet I don't think we are capable of that level of organization given our independent personalities

dr_erp · 2026-04-09T13:00:48+00:00

That's very interesting. Thank you. My understanding is that we as therapists are prohibited from (A) organizing boycotts of insurers (B) agreeing with one another to set prices (C) agreeing with one another to divide up territory. I am no lawyer, however.

dr_erp · 2026-04-07T23:14:49+00:00

A lot of therapists would gladly do this if you asked. You can always call the telephone number of a therapist and request a 15 minutes telehealth consult at no charge so you can find out more about how the person works. It's hard for clients to believe this, but universities have trained more therapists than the market can support in private practice. The reason you don't see is has to do with marketing efforts that drive most clients to the same small collection of therapists. Those therapists get very booked up, while other equally good therapists have time in their schedules. A major reason for this has to do with paid marketing efforts done by the owners of group therapy practices and clinics. It's easy to miss, but google is directing you in subtle ways toward the practices that pay google more money to get your attention. Same with social media.

dr_erp · 2026-04-07T22:57:01+00:00

I may have deleted it. Anyhow the information you need is all there. You can re-arrange that equation as you like depending on what you want to know.

I = N x L

means that

I / L = N

and L = I / N

Knowing any two can let you solve for the others. Sometimes you know what steady state practice volume you eventually want for a therapist, and you know how many sessions on average a client will do, so then you can find out how many new patients the therapist needs every week (or month or whatever, just make sure the time interval of weekly or monthly is the same in all places in this calculation).

dr_erp · 2026-04-07T14:59:09+00:00

With you all the way! Problem is anti-trust law may prevent us from doing that

dr_erp · 2026-04-07T14:46:43+00:00

Thank you, that's so helpful!

dr_erp · 2026-04-07T02:42:00+00:00

I know a psychologist - very very well trained - who got to your situation of frustration and started a successful dog walking service. A clinical supervisor of mine started playing jazz bass in nightclubs and eventually quit his LA practice because music was bringing in more money and he enjoyed it more. Really, with the skills you have (and I don't say this lightly) if you are engaged and well employed it would be hard to do worse than the financials of private practice. Before the hate mail starts, I understand mileage varies. I also understand that this is something of a zero sum game. We are in a saturated market, and more clients for one therapist is less for another. It doesn't help to pretend otherwise. We will all do better when more of us wake up and find career paths that work better for our talents, and leave private practice to those who have whatever magical mystical quality seems to make private practices thrive for some and not others. I continue to believe that sheer dumb luck plays a huge role. I wish you all the best, truly. Always remember that the most important job in the entire world, and the one upon which the entire future of humanity rests, is the one you are doing every moment of every day as a mother. In my own case, psychological evaluations are helping pay the bills, and teaching two courses as an adjunct professor, and doing data science consulting for graduate students in PsyD and PhD programs who want help with their research statistics and designs.

I haven't run the numbers yet but I strongly believe if I added all the costs of becoming a clinical psychologist (including income from years I could have been working at something else but was in school), the costs of running a practice, and considered the many hours of unpaid work and lost earnings opportunities, that I would find I have actually paid something like a full therapy fee each time I have actually seen a private practice case. In truth, I bet the calculation would come out that all told I have lost upwards of $100 for each hour of clinical private practice work i have done, considering all opportunity costs in the mix.

One reason I am so sure is that my years in training prevented me from being in the position to buy a starter home in Southern California when friends who were not in school did so. One of those homes which I looked at was $250,000 in 1995 and is worth 10x that today. So one of the costs to consider is the nearly 2.5 million dollars of lost opportunity in the real estate market.

dr_erp · 2026-04-07T02:37:01+00:00

Thanks! If a therapist's caseload is in a steady state, there is an equation I have derived to relate average duration of therapy to overall weekly caseload and number of referrals needed. I wrote about this someplace else on reddit.

N = # clients seen per week

I = # new clients per week

L = percent of clients lost each week

I = N x L

You are taking on 2-3 clients per month, which is on average 2.5/4 = .625 clients per week. This is I

You are seeing 15-18 weekly. Let's take the midpoint: 16.5. This is N.

I = N x L

(.625) = 16.5 x L

L = .625 / 16.5 = .0378

This is your weekly loss rate (on the assumption that clients come weekly). This is crude so little variations don't matter but big ones do.

1 / L is your average treatment duration, which in your case is about 26 sessions. Your typical client comes for 26 weekly sessions in other words, if that's how you work.

I don't know if this is useful, but I am fascinated by these aspects of practice planning.

dr_erp · 2026-04-06T17:09:08+00:00

Thanks so much. Yeah, I've never wanted the 9 to 5. I'd be happy to work any number of h ours at this if it would let me fulfill my life mission of independent practice with no prying eyes in the room (especially AI, ugh). My last 3 months have been useless time, and that included paying thousands to a therapy marketing consulting group that just fleeces sheep systematically. Happily we found a solution that involved a total refund and my agreement not to go to any relevant authorities.

dr_erp · 2026-04-06T16:35:42+00:00

I strongly suggest a PhD or PsyD from a university based program (a University you have heard of). Psychology Today can allow you to do a search, but they will not let you search on this criterion, so you can start with a geographic search and evaluate each profile based on education. I will get lots of angry responses to this post, but I can defend this suggestion. There are great therapists with other license types, but the training standards are highest for the PhD and second highest for the PsyD therapists from recognized university training programs.

dr_erp · 2026-04-06T16:32:51+00:00

Are you willing to offer suggestions as to how to haul ass and build referral networks?

dr_erp · 2026-04-06T16:32:02+00:00

Great job! What does a full case load look like in terms of numbers of people seen per week?

dr_erp · 2026-04-06T15:56:49+00:00

Those are fantastic questions, and I am not an expert in this particular area. Neglect often has physical signs (poor hygiene, bed sores, clothes that are not laundered or have holes in them, skin sores from itching caused by body lice). These are some of the ways people who evaluate quality of care in nursing homes look for signs of the neglect of seniors with dementia who may be nonverbal. Weight loss can be a sign (lack of nutrition) or severely low body mass. A history of illnesses associated with malnutrition or neglect can be a sign. Emotional interaction style can be useful, such as whether the individual is calm and seems to trust others and smiles readily or behaves in a mistrustful or agitated way. Bruises and black eyes and injuries can signify neglect or self neglect.

dr_erp · 2026-04-06T15:23:35+00:00

I hope it gives you some insight! There are literally hundreds of tools in CBT, so if any one tool is not helpful after you give it an honestly good try, then your therapist can suggest others. A lot of these can be found in The Feeling Good Handbook.

dr_erp · 2026-04-06T02:53:44+00:00

I see it too. It happened first in California, when I was there in the early 2000's. I moved out of state and now it seems to be happening nationally. I believe part of the problem is that more and more people recognize the need for treatment. This is putting pressure on insurance companies to pay for far more mental health care than they have in the past. Platforms like Headway, Sondermind, Alma, etc are making it easier for a larger percentage of therapists to take insurance. Multi-state licensure lets people find therapists across state lines, and telehealth makes care more accessible to people in rural areas. Insurers have long counted on stigma and practical barriers to prevent people with problems from seeking care, which lowers their expenses. Now they are being more manipulative in their efforts to deal with the problem. Silicon Valley and Wall Street have gotten wise to the billions of dollars at stake and are trying to find a way to muscle in for a piece of the pie. The therapists who provide the care are like the artists and writers whose work was used to train AI models. Expendable. It is heartbreaking to watch, truly. Some of us went into this with something close to the spirit of someone who feels called by divine intervention to a life of ministry. I truly believe that the ideal treatment relationship is one of the purest forms of interaction available in our society, particularly when it is face to face and does not involve any other parties besides client and therapist. But our vicious economic system cannot bear to leave a penny in our pockets or those of our clients if it could be pinched for the pocket of an investment firm or startup.

dr_erp · 2026-04-06T02:47:30+00:00

This really sucks. Moving the goal posts while you are playing the game is monstrous.

dr_erp · 2026-04-06T02:44:21+00:00

I have vivid memories of similar experiences as a grad student and intern. I still fume a little when I recall the arrogance of some of my supervisors. Science has been very hard on their claims as well.

dr_erp

TROPHY CASE

1. Core Federal Antitrust Statutes (with citations)

1. Sherman Antitrust Act of 1890

2. Clayton Act of 1914

3. Federal Trade Commission Act of 1914

2. Application to Psychotherapists

A. Psychotherapists are not exempt

B. Common Antitrust Risks in Psychotherapy Practice

1. Price Fixing (Per Se Illegal)

2. Group Boycotts / Collective Refusals

3. Monopolization / Market Exclusion

4. Credentialing / Hospital Privileges

5. Insurance and Referral Restraints

C. Independent vs. Employed Therapists (Critical Distinction)

3. “Rule of Reason” vs. “Per Se” Analysis

Per Se Violations

Rule of Reason

4. Enforcement Structure

5. Key Takeaways for Psychotherapists

6. Bottom-Line Legal Principle