Episode 378: The State of Therapy: What Therapists Are Afraid to Say Out Loud.

There is a particular kind of quiet that shows up around 9pm, after the notes are done and the last client has been held well. It is not relief. It is the low hum of wondering whether any of this holds. Whether the referrals keep coming. Whether AI eats the field. Whether the platform ads you keep scrolling past are describing your future.

Most of us do not say that out loud. Not at consultation group, not at the networking breakfast, and definitely not on LinkedIn. So we asked. Inside the Business School for Therapists classroom and across our broader community, we put out a simple prompt: what are you afraid to say out loud? The responses came back faster and more openly than we expected, and a theme showed up almost immediately. It was not that therapists are afraid. It was what we have all been trained to do with the fear once it arrives.

We have been coaching therapists since 2010, through fee increases, insurance exits, hiring decisions, and closures, and our trainings have reached more than 100,000 clinicians. Twenty years in, we have watched a lot of practice decisions get made from a nervous system that was never consulted. This episode is our conversation about that, plus a short guided reflection near the end that you can actually use.

You Cannot Success Your Way Out of Fear

The most striking thing in the classroom responses was who they came from. Not therapists in crisis. Therapists who are full. Therapists making the most money they have ever made. Therapists who got off the panel, raised the fee, filled the caseload, and did every single thing the business advice said to do.

And the fear was still there. Some version of it will not be enough, or it all falls apart tomorrow, or last year was a fluke I cannot repeat. Which tells you something important about the mechanism. If fear were a data problem, evidence would fix it. A full calendar would settle it. It does not, because fear is not running on your P&L. It is running on something older.

This matters practically, because most of us have built a plan around the wrong lever. We think we are three referrals from peace. We are not. Miranda's phrasing in the episode is the useful one: this is not something you can look at the math and resolve. It is something you have to be in practice about and be intentional about.

The takeaway: If your business goals are secretly a fear-management strategy, hitting them will not do what you are expecting. Treat the fear as its own work rather than a byproduct of not having enough clients yet.

Thinking About It Is Not Processing It

Here is the trap, plainly: thinking about a feeling can look and feel like working on it, while nothing actually moves. The hamster wheel gets faster. The insight count goes up. The sensation stays exactly where it was.

Most of us were trained into this. The clinical education many of us received was deeply intellectual, even around emotion. Transference and countertransference get discussed as cognitive events rather than physiological attunement. We learned to track someone else's body while disconnecting from our own, sometimes on purpose and sometimes just by absorbing how everyone around us practiced.

In our own work, the same shift showed up for both of us: resolution arrives through the physical, not the analytical. Kelly holds the confusion in mind, notices where it lands in the body, and stays with it, sometimes on a walk because movement keeps them from floating off. Miranda stays with the tightness or the stabbing or the tingling long enough to find that it does not last forever, and that something more open tends to be waiting on the other side of it. Journaling and pros-and-cons lists never delivered that consistently. Twenty minutes of sitting with herself often did.

The takeaway: If you have been circling the same fear for months with excellent insight and no relief, you have probably been thinking about it rather than feeling it. The route out runs through the body.

Ask Whether the Fear Is Even Yours

This is the question Kelly asks first, and the one we ask each other when one of us forgets: is this mine? Am I processing my own fear, or something systemic, or something ancestral, or something I picked up in a room this week?

Miranda's example from her own life: sitting with a financial fear and finding that a large share of the intensity was not hers at all. It was her father's, shaped by a failed business that failed for reasons specific to his circumstances and not remotely predictive of hers. Once she could see that clearly and be with it, the borrowed portion released. What remained was the smaller, realer piece that actually deserved her attention.

That smaller piece still matters. Real fear about rent, health insurance, and feeding your kids is not a distortion to be reframed away. But there is an enormous difference between making decisions inside a fear that is mostly inherited and making them inside the part that is genuinely yours to solve. The first produces panic pricing and contracts you should not sign. The second produces plans.

The takeaway: Before you act on a fear, sort it. What part is yours, and what part arrived from family, colleagues, or the internet? You can only work with the part that belongs to you.

Sometimes the Terror Is Pointing at Something You Want

We talk in this episode about a longtime client of Miranda's whose worst-case scenario was the classic one: I am going to end up living in a van down by the river. That was the shape of the dread. It came up over and over.

She now lives in a van, by choice, with all the joy in the world. When she finally sat with the fear instead of arguing with it, two things were tangled together: a fear of not enough, and a real desire for freedom and closeness to nature. Once they were separated, she could build the version with safety in it, with a home base, on purpose.

That untangling is common for us specifically, because so many of us are doing something our families and our mentors did not do. We are attempting a life that has not been modeled for us. The unfamiliarity of it registers in the body as danger, and it is easy to read that signal as a warning about the thing itself rather than as the ordinary discomfort of being early.

The takeaway: Ask whether the catastrophe you keep imagining contains something you actually want. Sometimes the fear is doing a poor job of describing a desire.

Look Hard at Who You Are Taking Advice From

Kelly brings a coaching call from earlier that week into the conversation. A therapist had done the work on her relationship with money, raised her rate, and then gone to a networking event with friends she trained with and later worked alongside at Kaiser, where pay has been flat for years. She mentioned wanting more clients. Everyone jumped in with the same fix: join a platform, take a hundred dollars an hour. About a third of what she had just decided she was worth.

She declined. Not because she felt certain, but because she had done enough work beforehand to recognize the advice as an expression of their fear rather than an assessment of her situation. She could tell whose tension she was holding.

This is where the somatic work stops being a wellness activity and starts being a business skill. The better you know your own baseline, the faster you notice when a room's vibe is not yours. It works the other direction too: that odd, off feeling at some therapist gatherings, the disdain or resentment or flatness under the conversation, is usually unheld fear looking for company.

The takeaway: Fear is contagious, and it travels disguised as practical advice. Notice whether the person recommending your next move is describing your circumstances or managing their own dread.

The Platform Pitch Is Built on the Fear That You Cannot Do This Alone

Let us be direct about the business model. Platforms are not primarily selling caseload. They are selling relief from the fear that you will not be able to fill a practice yourself, and they are selling it with incomplete math.

The number in the calculator is gross. Before taxes. Before self-employment tax. Before health insurance you now buy yourself. With no vacation, no sick time, no buffer, and no floor under the rate, because these contracts can change. And the comparison people make is usually to an employed position where benefits and employer-paid taxes were quietly doing a lot of work in the background.

The contracts themselves are one-sided, and our point is not that this is scandalous. Companies write contracts in their own favor; that is what companies do. The problem is signing one while expecting it to be mutual. Sit with the comparison for a second: someone you have never met, who gets paid if you say yes, told you great things about a stranger, and now your colleagues are telling you to marry him. We are therapists. We know exactly how that story goes when a client tells it to us.

The takeaway: Read the contract like a clinician, not like someone who needs rescuing. If the pitch only works when you are scared, that is information about the pitch.

Saying It Out Loud Is Where the Grip Loosens

The most repeated response to the classroom thread was not advice. It was some version of reading this, I feel seen.

Here is why that matters structurally: oppression works by isolation. Holding a fear privately keeps it sealed and lets it grow strange. Reaching out is not just comforting; it is a small act of refusal, and it is the mechanism by which a fear stops being a secret and starts being something you can look at. We noticed it in ourselves too while reading the submissions. Hearing what colleagues were most afraid to name did not raise our own fear. It softened us.

The other question worth carrying around: how do you feel toward the fear? Most of us meet it with rejection, or shame about having it at all, or irritation that it is back again. That reaction shapes everything downstream. Fear met with more fear compounds. Fear met with some curiosity and a little warmth tends to loosen, even when the underlying circumstances have not changed at all.

Because they will not always change. AI is here. Platforms are consolidating. Reimbursement is what it is. What can change is your capacity to hold all of that without it running your pricing, your boundaries, and your Sunday nights.

The takeaway: Say the thing to someone. Not to get it solved, but because a fear spoken out loud takes up less room than a fear kept.

Read the full episode transcript

Kelly: (00:00) Welcome back to our podcast, Starting a Counseling Practice Success Stories. Today is not a success story. Today you're getting me and the amazing Miranda Palmer.

Miranda: (00:14) And me, not me, is Kelly Higdon, who is a fantastic friggin' human. And if you just suddenly found us, we've been together as business partners since twenty ten. So much has changed since then in our profession, and there's a lot of things that have stayed the same. Some good, some not so good.

But today we're going to talk about the state of the profession and what's happening in July of 2026. What are we navigating as therapists, as human beings, as practice owners, or potential practice owners? What are the things happening out there that we're keeping an eye on? And we thought today we'd talk about health insurance as a starting point, from a different perspective. Because as business owners, as people who provide health insurance, we're already planning what kind of benefits we're offering our team of private practice coaches and our operational team for 2027.

We're having the experience personally of looking at the way our benefits came back last year as subsidies were expiring for our employees, and how we keep seeing the premiums go up and the deductibles go up while the actual coverage goes down. What we've noticed is that while technically we have health insurance, realistically our insurance is mostly just an out. It's not really giving a lot back. We're paying premiums, and because we have high deductible plans, and because it's hard to get care, we end up not actually utilizing our insurance. We're finding that paying out of pocket to see a primary care doctor is cheaper than going through someone who takes our insurance.

Checkups are quote unquote covered, so you get one annual thing per year. But what does that mean if I'm getting one annual checkup and I've invested five figures in premiums for it? And the promise is that if I had a catastrophic event, and I only paid several thousand more, that event would be covered.

People are trying to figure out how to navigate this. Some people are leaving the country because they've realized they can get better care elsewhere, that they can get comprehensive or even basic or catastrophic care in other countries, and pay less for the medications they or their children need. Some people are banding together into other kinds of plans and programs, saying, wait, when insurance companies were first created they were nonprofit organizations to help people in the hospital for something unexpected and catastrophic, so people were not bankrupted.

And people have health insurance, and health insurance for health care is still bankrupting people. So something's not working in the system. And then, how does this all impact us in terms of mental health care? For those of you who have been accepting insurance specifically because you want to make your care accessible: what happens when the people you wanted to create accessibility for do not have health insurance, because health insurance isn't actually creating accessibility for them?

Kelly: (05:20) And that's what we've seen change with the new big, beautiful bill, and how it changes the subsidies. A lot of subsidies were lost.

Miranda: (05:33) For clarity's sake, it isn't that the bill did anything specific to the subsidies. It's that the subsidies went out after a certain period of time and it did not renew them.

Kelly: (05:50) Yeah, it did not renew them.

Miranda: (05:52) Regardless of the bill, Congress could have extended the subsidies and they did not. They said, actually, we don't need that. This is great. It's working as intended. We like the way that health insurance is in America, and we think these are perfectly appropriate rates. And at the same time the subsidies were expiring, insurance commissioners were giving the okay for insurance companies to increase their premiums by double digits, depending on what state you're in.

There are a lot of people who've been involved in allowing the cost to be what it is. It isn't just insurance companies. Your insurance commissioner, who might be appointed but is probably elected. Every single member of Congress. They all allowed this to happen and they're not really doing anything about it, while they all have insurance that doesn't have any deductible. They have access to great care, working a hundred days a year. Interesting. Huh?

Kelly: (07:06) And they're estimating 2.6 million people are no longer insured because these subsidies are now gone. The Department of Health and Human Services is saying it's because they cracked down on fraudulent accounts, but analysts are saying no, the subsidies are gone and people can no longer afford to have the health plan. So more and more people are not insured, and the very people that therapists want to serve by being on insurance panels are no longer on insurance panels. So then what do we do about access? I foresee that continuing unless something changes with the ACA or the way we do health care in this country.

And some physicians and doctor groups are speaking up. They're providing a different kind of service. In primary care, you can have a membership model where you pay a monthly fee and then you can go to the doctor when you need to. And then they offer things like the X-ray or the MRI at cost or lower, much lower than what it would be through your insurance company. I don't know if you've ever done this, but if you had a procedure or you needed some sort of scan or blood work, ask what it would cost if it was just cash. For me, sometimes it's less than if I billed through my insurance because of my deductible. Yes, I'm contributing to my deductible, but I'm probably never going to get down that deductible this year. The cost is so inflated when it's billed through insurance companies.

Ready to Build a Practice That Does Not Run on Fear?

None of this is a suggestion to stop paying attention. Miranda brings up The Gift of Fear near the end for a reason. Fear is protective. It is a signal worth having. The problem is not that therapists feel it; the problem is what happens when it goes unheld long enough to start making decisions on your behalf.

What we see in coaching, over and over, is that the practical work goes better once the nervous system is in the room. The therapist who has sorted whose fear is whose can hear a bad contract for what it is. The therapist who can stay with discomfort for two minutes can sit in a fee conversation without folding. The therapist who has said the scary thing to one colleague stops treating a slow month as proof of collapse. The business skills are the same skills either way; the difference is who is driving.

That is a large part of what Business School for Therapists is actually for. It is a blend of live coaching and self-paced curriculum, and the piece people are often most surprised by is the community: a room of clinicians who normalize niching, real fees, and clinical depth, and who will also tell you honestly when the fear you are describing sounds like somebody else's. That classroom thread is where this whole episode started. Twenty years in, it is the work we wish someone had handed us when we were spending our own weekends figuring this out.

If you want to start smaller, start with the reflection at the end of this episode. Five minutes with your own body, without trying to change anything. For most of us, that is a bigger ask than another marketing tactic, which is probably the point. When you are ready for company while you do the harder version, come find us at zynnyme.com, or keep listening; there are hundreds of episodes here of therapists building this on their own terms.

Key Takeaways for Therapists

• A full caseload does not resolve fear, because fear is not responding to your numbers

• Thinking about a feeling can substitute for processing it; somatic work is where resolution tends to land

• Ask "is this even mine?" before acting, and separate inherited fear from the part that is actually yours

• The catastrophe you keep imagining sometimes contains a desire worth building toward on purpose

• Fear-based advice spreads quickly among colleagues and often arrives disguised as practical guidance

• Platform math is usually gross, unprotected, and compared against an employed role that included hidden benefits

• Contracts written in a company's favor are normal; signing them expecting mutuality is the error

• Isolation strengthens fear, and naming it to another person loosens its grip even when circumstances do not change

Resources

• Watch this episode on YouTube: https://youtu.be/Y_RLA8C1xHk

• The Gift of Fear by Gavin de Becker: https://giftoffear.com/book

• Business School for Therapists: https://www.zynnyme.com

• Listen on Apple Podcasts: https://podcasts.apple.com/us/podcast/starting-a-counseling-practice-with-kelly/id1398391639

• Listen on Spotify: https://open.spotify.com/show/7K8TQ13vJL4L3IvtWLLXV3

About the Authors: Kelly Higdon and Miranda Palmer are the co-founders of ZynnyMe and creators of Business School for Therapists. Since 2010, they've helped tens of thousands of therapists build sustainable practices through organic digital marketing strategies that actually work—without wasting money on ads or time on tactics that don't convert. Because your practice deserves to be found by the people who need you most. Learn more here.