The State of Therapy: Surviving, Thriving, and (Un)Learning the Rules
So, you want to build (or grow) a private practice. Maybe you’ve got a backlog of curiosity, the kind of insomnia that only insurance audits can bring, or you’re just tired of being squeezed between paperwork and a checkout timer at the local therapy agency. Or, if you’re honest, you’re ready to put some boundaries up between yourself and those relentless insurance emails. You are definitely not alone.
In this episode, join Kelly and Miranda for a real-world check-in on the ever-evolving landscape of mental health and private practice.
Forget dry industry reports or doom-and-gloom roundups. This conversation feels more like a lively group supervision session with your most honest colleagues: part big-picture reality check, part personal vent session, and part no-nonsense pep talk.
If you’re itching for truth bombs, practical advice, and mindset shifts sharper than your most existential Sunday night, keep reading.
Value-Based Care: Shedding Light On the Buzzwords
Let’s call it out: value-based care is the corporate flavor of the week, and therapists everywhere are left trying to decipher what this means for their income and sanity. The insurance world has always been a maze, but recently, as Kelly and Miranda discussed, it’s beginning to look more like a carnival funhouse, complete with mirrors designed to distract you from the real issue: Who’s taking on the risk? (Spoiler: It’s still you.)
Kelly breaks it down: “It means that basically, like, we're looking at how payment is determined between you, the provider, and the insurance company, and looking at a value-based care arrangement, meaning that you assign some sort of value to the therapy and determine that you will be paid based upon that value.”
Sounds fine… until you unpeel the layers. Miranda reads from the article: “A value based care arrangement can mean many things, including… full risk for the for the provider, pay for performance… or even shared savings, whatever that might mean.”
Translation: More hoops, less certainty, and, yep, even more of the risk shifting away from insurance giants onto the folks actually doing the work.
Takeaway: If “shared risk” has your stomach in knots, you’re not overreacting. These models are designed to protect the payer, not the provider.
The Real Cost of Risk: Therapists Taking the Hit
Miranda got curious (as therapists do) and threw the article into ChatGPT, asking for some objective perspective. The AI shot back, “Therapists already absorb a disproportionate amount of risk in insurance based care. They sometimes wait months to be reimbursed if at all. They face clawbacks for care they've… already been delivered. They rarely have transparency into why claims are denied. They get paid far beyond their value with stagnant rates for years and are burdened with unpaid admin time documentation treatment plans and audits.”
Sound familiar? That’s not an anomaly. Data backs this up - research shows in-network rates have declined over the last decade, while your student loans, rent, and latte prices have done precisely the opposite. Miranda nailed the punchline: “As your costs have been increasing, overarching in network rates have been already declining. And what they're saying is they want the option to reduce your rates even further.”
If that doesn’t induce the urge to eat your GFE paperwork, nothing will.
When “Outcomes” Aren’t What They Seem
The kicker in this brave new value-based world? Insurance companies aren’t measuring what you think. Kelly calls it out: “This is sort of that kind of they make this moral high ground, which is really not, it’s false. It is about their savings. That's what they care about. Are you, as a provider, going to save the money?”
Turns out, the “therapeutic alliance” they trumpet is reduced to numbers: “Three sessions with the same therapist within a defined period of time” is their proxy for outcomes. Miranda points out, “the therapeutic alliance and someone to engage people in therapy has the best, like, overarching outcome.” But Kelly isn’t buying the spin: “It's not really about therapeutic alliance. It's… about their savings. That's what they care about.”
Lesson: Insurance companies may say they care about your outcomes, but their “valuing” is all about their bottom line, not yours.
The Real Cost: More Than the Paycheck
Here’s where things get vulnerable. Both Miranda and Kelly open up about the real emotional and physical toll that this system exacts, on you. Burnout isn’t a “nice” way of saying, “I need a vacation.” It often shows up as genuine health issues.
Miranda lays it out: “...is it that you have major depression disorder, or is it that you're burnt out from working within a broken system?… If you're working within a broken system Miranda that is what is fueling your symptoms, will SSRIs help? Will therapy help?… Or do you say, actually, probably the only thing that's going to, quote, unquote, fix the anxiety is them being in a safe home. Right?”
Kelly shares: “I was one of those people. Right? Ended up in the hospital with… migraines… chronic pain and fibromyalgia and just a host of things. And it's taken a long time to unravel that. And I think that is why I do love private practice. I'm not saying it's a perfect solution… But what becomes more of within my creative control and within my sovereignty, is, you know, creating a business that actually a system that actually supports me and my body and my nervous system in a way that capitalistic corporations cannot do that and will not do that.”
Takeaway: This isn’t about “self-care”; it’s about choosing structures that actually support you on a physiological and existential level.
Private Practice as Resistance (and Recovery!)
Don’t let the gloom fool you, Miranda and Kelly don’t just diagnose the problem. They prescribe a real antidote: building a private practice isn’t just about profit; it’s about reclaiming your health and wholeness.
Miranda shares her story: “...when I initially started my private practice, I would see 10 clients a day. Back to back, five clients before I would start, sometimes at six in the morning. Right? And, again, I in my mind, initially, this was so much better because I had time off to be with my infant. Right? Like, I'm thinking I'm unraveling the system even within that, but, like, here's how, you know, shifted my void my my scenario was where I'm doing that while also working for, teaching at local universities in person and online while also being the primary caregiver for an infant and breastfeeding…”
Slowly, she unlearned, including from gaslighting medical professionals, how to listen to her body. “I'm a completely different kind of healer. The way that I take care of my body is so different… and it's the only thing that's been effective for me.”
Lesson: Building a private practice is a radical act of self-trust. You get to choose how you structure your work, what’s sustainable, and, ultimately, how you show up for both your clients and yourself.
The Metrics That Matter: Track What YOU Value
So, what does this look like when insurance giants and their “outcome measures” aren’t calling the shots?
Miranda and Kelly have been teaching therapists for years to track meaningful outcomes, not just what the payers want to see, but what actually moves the needle on clinical change and business sustainability. Miranda breaks it down:
Weekly Care: “How many people are you actually holding to this is the treatment plan that will work?... Ninety-five percent of therapists say it's a weekly person every single time.”
Mutual Termination: “Are you actually getting to the end of therapy where you guys are saying goodbye along the way?”
Outcomes Conversations: “Are you actually tracking and checking in with your client briefly at the end and/or beginning of every single session as well as every four to six weeks?”
Session Length: “Do you actually know how long it takes if you have a mutual termination for somebody to get to a point of saying, ‘Wow. Therapy really worked, and I'm ready to graduate.’?”
And don’t forget the power in talking transparently with clients about these measures: “Being able to tell a client, you know, look. I track outcomes. This is very important to me. I'm not interested in you coming here just to vent and then leave not feeling different.”
Key Tip: Tracking outcomes isn’t just for the insurance company; it’s for your own clarity, confidence, and clinical impact.
Mindset: From Overworked Martyr to Empowered Owner
Miranda and Kelly don’t mince words about the dangerous cultural myth that therapists must sacrifice themselves to fill the gaps left by broken systems. Kelly says, “...that's the common theme in private practice and just for therapists in general is that we continuously try to stand in the gap of systems that are larger than us, more profitable than us, and far more broken.”
You don’t have to fix the system alone. You shouldn’t try to fix it by pushing yourself to “make up the difference” and risk your own health in the process. (And, no, another bubble bath isn’t the answer.)
Community, Support, and the Power of (Un)Learning
This episode is a case study in vulnerability and connection, two things the therapy world knows at heart, but often forgets in the struggle for business survival. Miranda reminds us, “We have more free resources on our website than any other private coast you will Miranda. And a lot of people will say it's not really great for business, but for us, we want to provide as much accessibility as we can while also marketing our program because that's also how, like, what pays for us to be able to give back.”
What does real support look like? Community, accountability, and evidence that yes, it’s possible to build (and sustain!) a practice where both you and your clients thrive.
Ready to Reclaim Your Practice…and Your Wellbeing?
Whether you’re new to private practice or decades in, there’s never been a more important moment to take stock: are you carrying more than your fair share of the risk? Are you bending over backward to patch up a system that will never love you back? If so, you’re not alone, and there are resources, strategies, and communities ready to help you build something better.
Miranda and Kelly have been helping therapists ditch burnout and build sustainable, joyful practices for years. Their Business School for Therapists is a step-by-step program designed to support your business goals, clinical impact, and personal wellbeing, all while dodging those “capitalistic corporation” traps.
Curious? Ready to break up with burnout and create a practice that supports you just as much as your clients? Check out Business School for Therapists and dive into a free treasure trove of resources & trainings waiting for you here.
Here’s to your thriving body, business, and spirit. You deserve it.
