By: Amy Marschall, PsyD, Freelance Columnist

Most people probably have an idea in their mind of what a therapist’s job entails. Show up, meet with clients, say something groundbreaking, and collect payments. Unless you have worked in the field, your understanding of therapists is probably limited to media portrayals and your own experience in therapy, if you’ve received treatment yourself. Unfortunately, most portrayals are limited or outright wrong, and so much of the work of being a therapist happens outside of the scheduled sessions.

I was asked to share a peek into my work as a psychologist running a private practice to demystify what being a therapist looks like. Of course, this is just my own experience and not a standard – other therapists will probably have different routines and responsibilities.

Note: Any references to clinical work, while based on my experience as a psychologist, are fictionalized. The examples mentioned are inspired by themes I have seen in my work over long periods of time and do not refer to a specific client.

Clinical Work

Therapy sessions are usually the first thing most people think of when I mention that I am a psychologist. In my practice, though, this is probably the smallest demand on my time. I see about 10 to 15 therapy clients per week due to other demands on my time and my own mental health balance.

My ethics code requires that I be mindful and not see more clients than I can handle, as overworking myself can lead to lower quality of care for clients (not to mention that I am also a human being who deserves to have my needs met, just like my clients). All mental health professionals are at risk for compassion fatigue, and since one of my clinical specializations is childhood trauma, I need to be extra aware of how it affects my mental health to hear people’s stories day after day.

As a psychologist, I am able to conduct psychological evaluations in addition to therapy. Other types of therapists (clinical social workers, licensed counselors, marriage and family therapists, et cetera) typically do not offer this service, so they might see more therapy clients than I do. Depending on the week, I complete three to five evaluations, which consist of intakes, administering assessments, scoring, writing up reports, and reviewing results with clients. This takes a different type of energy than therapy sessions. Assessments also cost more because of the overhead involved – every time I administer a measure, I have to purchase the forms or scoring report.

I am very fortunate to have a private practice because, as my own boss, I get to honor my personal limits around clinical work. Most organizations have requirements for “productivity” (the minimum number of sessions you must have per week in order to stay employed). Therapists who work for these organizations might not have the flexibility to step back or reduce their hours if they start struggling with burnout, and they might be required to see clients back-to-back all day.

Documentation and Consultation

As a graduate student, I was taught, “If you don’t document, it didn’t happen.” In addition to keeping progress notes of all my sessions, any time I interact with a client, potential client, legal guardian, teacher, or anyone on a client’s treatment team, I have to document the interaction. My electronic health record (the system that I use to keep all of my clients’ charts and records organized) has a great system that helps me be efficient, but this still takes up a significant amount of time.

Another ethical standard for my work is consultation. Basically, if I have any concerns about my work or the quality of care I am providing to my clients, I need to talk to other professionals and get feedback about how to be better at my job. If I refer to a specific client in consultation, I do not share identifying information, but a colleague might have feedback about interventions I could try to better help them. This is not an opportunity to gossip about my clients but an important resource to ensure that they are getting the best possible care.

And, of course, I have to document my consultations. Typically, neither of these activities are “billable,” meaning that although they are required, I am not paid for the time.

Communication Outside of Sessions

Sometimes, a client or their legal guardian needs to speak to me outside of the scheduled session time. They might have a question, need to reschedule, or have an update for me. Since I cannot bill insurance for these communications, some therapists charge clients for this (which is fair – it is a demand on their time), but since this is generally not allowed if you accept Medicare or Medicaid, I personally do not.

In addition to responding to messages from my clients, I receive communications about new referrals that I respond to. My response might be information about my practice and helping them get scheduled, or it might involve me finding another provider if I cannot take the referral. I do not have openings for new therapy clients right now, so I sometimes have to respond to people seeking therapy with information about other providers. I also sometimes get referrals for evaluations that are outside my scope of practice (they need a type of test I am not trained to give, or they need a recommendation for something that I am not qualified to speak to), and I need to let them know of other agencies that might be able to help them.

Billing

Billing is probably my least favorite part of my job. I have to submit claims to insurance companies and invoice clients for their out-of-pocket costs. After submitting bills to insurance, I still have to follow up about claims that they “lost,” arbitrary denials, and partial payments. At least once per week I spend more than an hour on hold with an insurance company to figure out why a covered service was not paid.

If I bill something incorrectly, the insurance company will not pay the claim. I have had this happen because I put my NPI Type 1 where they wanted me to list my NPI Type 2 (even though both numbers bring up my practice in their system). When this happens, they might let me know the claim was denied, and that denial might indicate a reason why. Other times, they do not tell me it was denied and simply do not send a check. Every few months, I go through my system and figure out which claims are unpaid, and then I have to discover why they were not paid. It is the world’s worst scavenger hunt.

Incidentally, this is one of the reasons why many of my colleagues do not accept health insurance.

I also have to invoice my clients for their co-pays, deductibles, and any non-covered services as appropriate. This adds up to a pretty significant demand on my time, and while billing technically generates income, I do not get to bill the time spent billing.

If you have ever wondered why therapy sessions cost what they do, remember that we only get compensated for about one-third of our time, and we have to assume that we will simply not collect on some of those hours.

Non-Clinical Work/Side Hustles

Some therapists devote all of their work time to clinical tasks, and that is fine. Personally, I have several “side hustles,” including writing articles like this one, teaching continuing education, blogging, and consultation. The added income allows me to be more financially stable, and it means I am not fully reliant on clinical income to get by. So if a client has a ridiculously high deductible or is uninsured, I can offer more pro bono or low cost services without sacrificing my ability to pay my own bills.

Of course, this comes with its own set of demands and challenges. For consultation services, I often have companies assuming I will work for free. In one instance, a company worth almost $200 billion balked at the idea that I would want to be paid for offering my expertise on a mental health app they were developing. The app would, of course, be sold for a profit, but why would I charge for consulting with them? Didn’t I want to help people?

Overall, though, I really enjoy these kinds of gigs because they allow me to get accurate, helpful information and resources out to a larger audience than I see in individual therapy sessions. The fact that it also frees me up to offer more affordable therapy services is a bonus.

When I’m “Off The Clock”

As much as I love my job, my “off the clock” time is essential for my own mental health and self-care. There is a misconception that therapists are therapists all the time, to every person they interact with. I have gotten unsolicited feedback from many strangers that I was “not acting like a therapist” in my interactions with them, when they are not my client and are not paying for my therapy services. If I were to try to be a therapist to someone who had not consented to being my client, that would be just as wrong and problematic as someone assuming that I would act in that role for them for free during my down time.

Once when I was having wifi installed at an apartment, the company put my job title on the work order. The tech they sent asked me, “Are you really a psychologist?” and then proceeded to spend an hour telling me about his mother’s death despite me continuously trying to change the subject back to the service I was paying him to provide. He ended up doing the installation wrong, and when the second tech arrived, I asked him not to trauma dump on me. He then started telling me about the problems in his marriage.

I have started listing my profession as an auditor with the IRS.

To sum up, being a therapist is so much more than what happens in our sessions. As much as I love my job, it comes with stressors and challenges. And of course, I wouldn’t trade it for anything.