False Profits, or, Thera-nos

Note: This essay first appeared in Carter’s “Psycho Analyst” substack on April 13, 2025.

When I first became a social worker, you were not permitted to intern as a graduate student in someone’s private practice, nor were you permitted to work in a private practice while accruing hours towards your independent license. If you wanted to become a social worker, you had to work in public agency-based practice for your first four years (two as a student, two post-graduate prior to your full licensure).

Increasingly, this is no longer true. It is becoming commonplace for social workers to spend the entirety of their careers working in private practice. This is a big problem—but not for the reasons that some people think. The problem isn’t just about accessibility or values, though these matter; it’s about the increasing intrusion of for-profit entities and incentives into social work training, corrupting the educational experience of new social workers and the standard of patient care at the same time.

Beyond Unfaithful Angels

There is a longstanding and quite well-founded argument within social work; let’s call it the Unfaithful Angels argument. Unfaithful Angels: How Social Work Has Abandoned its Mission is a now 30-year-old book by Harry Specht and Mark Courtney. Specht and Courtney argue, broadly, that the widespread move in social work away from agency-based social welfare work and towards private psychotherapy practice amounts to an abandonment of the core values of the profession and the core constituency we are meant to serve (i.e. the poor). This is, on the whole, a fair critique, and one that has aged pretty well—even if, from an abolitionist perspective, I don’t share Specht and Courtney’s view of social welfare practice as angelic.

Nonetheless, for many years, the identity of social work as a profession was uniquely linked to public service. To become a social worker, you trained for years in public agencies, took required coursework on public policy in graduate school (something that is not required of any other clinical profession, I might add), and were socialized to take on the identity of a (long-suffering) public servant.

The requirement to train in agencies had many virtues, but one that was under-appreciated is that these agencies were teaching-oriented institutions, whether public or nonprofit, where you received clinical supervision that was primarily oriented to making you better at your job. These institutions functioned like teaching hospitals do in medicine, and in fact many social workers did their training in teaching hospitals. Of course, supervision is an authority-based relationship, and any authority-based relationship is vulnerable to corruption. In any agency, your supervisor might be more focused on their own convenience or reputation than on your growth—but they didn’t stand to make or lose money based on your work.

This is what has changed. The result is increasingly expansive systems of care based on foundational and irreconcilable conflicts of interest (that is, corruption), and what one might call the enshittification of social work training.

Social Work Training, Enshittified

To be clear: there are multiple sources of enshittification in social work training, and much to be said about the problems of social work education in the university especially. I’m saving that discussion for another day, and focusing on problems in social work’s signature pedagogy—field education, or, the years you spend in supervised clinical practice before you earn your own independent license that allows you to fly solo and see patients without supervision.

This story starts long before Covid, but Covid was a pivot point. For many years pre-2020, it had become an increasingly bum deal to work as an agency-based social worker, the kind of person who would supervise trainees. The pay was abysmal, especially relative to the required debt load; caseloads were rising, even as the people on one’s caseload were becoming more acutely risky and clinically complex; students were increasingly underprepared, and agencies were increasingly stuck doing work they weren’t good at or that just didn’t work for patients, for a host of reasons too long to enumerate here.

Still, many people stayed in agency-based practice, even though you could theoretically craft a cushier gig for yourself in private practice, in part because the startup costs of private practice were substantial. You had to get paneled with insurance companies, find and furnish an office, and have money to burn on these expenses and lost wages while you built up a caseload, which could take months; in the Northeast, it was a $10-20k investment, on average, when I did it in 2017, and many people could not float themselves this much capital to start a business. So, while the unfaithful angels (such as myself, flap flap) did keep flying off to private practice, we were a flock, not a murmuration; and, we were mostly people who were already financially stable (not me) or who were particularly committed to long-term, intensive types of psychotherapy that agencies had mainly eschewed (me).

Covid changed this completely. Suddenly, most people couldn’t do, or didn’t want to do, in-person therapy. The need to rent an office evaporated, telehealth became much more accepted by insurance companies and patients, and many easy to use and HIPAA-compliant platforms became available. Meanwhile, agency-based practice became grinding, dangerous, and often downright impossible during Covid, without any hazard pay or end in sight. The result was a mass staff exodus out of agency-based practice and into private practice.

This tipped an already-suffering mental health ecosystem into collapse. You see, it’s actually quite difficult to see Medicaid patients in private practice in many states; in Massachusetts, for example, there are legal restrictions on charging Medicaid patients for no-shows and late cancellations, which really hurt the therapist’s bottom line, and Medicaid billing and paperwork requirements are generally onerous, even as Medicaid’s reimbursement rates are lower than commercial insurance or Medicare. Whatever one’s values, it’s often bad business to see Medicaid patients for psychotherapy in private practice, so people rarely do it.

This left all these new private practitioners competing for patients with commercial insurance, or (better still) patients who could pay out of pocket. But this is not an infinite pool, so the influx of therapists into private practice created a supply-side glut for a specific kind of (relatively richer) patient, even as it severely worsened a supply-side shortage for many of the most vulnerable patients (i.e. relatively poorer people). This meant that many of these new private practitioners could never actually build a full caseload; they often didn’t wind up making much (or any) more money than they did in the agency, even though they had suddenly taken on much more responsibility and risk.

The other problem is that many of these private practitioners were lacking in business acumen, clinical acumen, or (too often) both. They weren’t ready to do what they were doing clinically; they struggled to secure referrals in the Tinder-like marketplace of online shrinks, and they made a lot less money than they thought they would. They were worn out by the constant wrestling with insurance companies, who didn’t take long to tighten up on requirements and resume predatory practices as the acute phase of the pandemic tapered off.

Many of these therapists actually wanted to go back to agencies. They wanted a benefits package, paid time off, someone else on call for patient crises. They didn’t want to spend all day staring at the computer doing telehealth. But many tried to return to the agency-based world, only to find that the mass flight from these agencies had caused loads of them to close, and hobbled (that is, enshittified) the ones that remained open. These migration patterns had created an environment where many therapists were, in a meaningful sense, professionally stuck, even as the demand for mental health services continued to explode. It was also an environment in which none of the options for patients were really any good.

We had a problem: there was no easy way for people who needed therapy to get connected to someone well-equipped to provide it. Predictably, capitalists entered the fray, ever eager to make money as middle men.

The Rise of Psychotherapy Carpetbaggers

I’m using this category of psychotherapy carpetbaggers to describe two general types of corporate entities. The first is the sort of giant, venture capital-backed entities you hear constantly advertised on podcasts—BetterHelp, AmWell, et al. The second, less-visible entities are private group psychotherapy practices, often owned by a single individual, that have grown massively, maintaining staffs of dozens (even hundreds) of clinicians, most of whom are in highly precarious labor arrangements—they are pre-licensure trainees, and/or fee-for-service clinicians paid hourly for clinical piecework.

In each of these situations, the corporate entity strikes a deal with the individual clinician: we’ll handle the logistics and make sure you get referrals, and you give us a (big) cut of what the insurance company pays for the service you render. On a strictly functionalist level, this might sound like a reasonable trade. The problem is that, in each case, the corporate entity finds it is in its own interest to dictate the terms of the psychotherapy, explicitly or implicitly. They create pressures and incentive structures to direct the clinician to do what is most profitable, which is often not what is most ethical for the patient or most viable for the clinician.

In the case of entities like BetterHelp, this takes forms like incentivizing the therapist by paying them per patient contact; in other words, they are rewarded for doing things like exchanging texts. Except in very unusual circumstances, like in standard model DBT for patients with borderline personality disorder, this is an absolutely terrible idea for most patients, a basic fact most clinicians learn in graduate school. Yet, in the BetterHelp context, the corporation sees a consumer demand for this behavior, and so incentivizes the clinicians to do it, against what should be their better judgment.

As inclined as I am to roast giant corporations, though, I actually see these private group practices as doing something much more troubling. Again: typically, these practices have a single owner; they love to call themselves “founders,” and they also love to make up names for their practices that involve words like “Center” and “Institute,” which imply that they are august institutions instead of random private businesses.

These practices have come to fill a void left by nonprofit community mental health agencies—including, most problematically, taking on the training and supervision of graduate students and prelicensure clinicians who need to work under the supervision of a fully licensed colleague. These practices are generally structured in such a way that graduate students are unpaid or barely paid (this was also the case in the agencies, maddeningly), and in which prelicensed clinicians earn about 40-50% of what the insurance reimburses for the services they render; in exchange for this, they receive their legally required clinical supervision, access to the resources they need to do their work (like electronic medical records platforms, billing support), and, sometimes, the continuing education opportunities they need to get and keep their licenses.

This is a bum deal, for several reasons.

1. The services these owners render to their employees are not remotely worth the 50% cut they typically take. These days, it is fairly inexpensive to get HIPAA-compliant telehealth platforms, electronic medical records software, billing services, and the like; I only spend about $350 a year on these services for my private practice. More to the point . . .
2. You can buy very high-quality clinical supervision privately for a fraction of the cost these practices skim off your paycheck.
3. The supervision that is provided in these practices is also, in my experience, corrupt. It is corrupt for two major reasons.

1. 1. The owner of the business has a fundamental conflict of interest in their role as a clinical supervisor. They have every reason in the world to advise their supervisees to conduct treatment in whatever manner enhances their personal profits and limits their personal liabilities. Of course, they are ethically enjoined from doing that, but we are all very easily (self-)deluded when money’s on the line.
   2. Quite often, the owners of these practices are substantively incompetent. They have made supervising their business, but they have no business supervising. They are supervising not because they are legitimately expert clinicians in the eyes of professional peers who should be training the next generation, although they generally front like they are. Rather, they are supervising because it is a pathway to making the most money you can possibly make as a clinician these days. Like Elizabeth Holmes, they are often pretending to an expertise they do not actually have, and trying to appeal to an audience that isn’t well-equipped to know the difference between them and a genuine expert.

Profits for Prophets

Let me run the numbers for you, for illustrative purposes.

Let’s say a typical 50-minute therapy session pays about $100, if the patient has Medicare or commercial insurance. These practices often set a productivity requirement that requires prelicensed therapists to see 30+ patients per week. This may not sound high until you remember all the other things the therapist has to do (e.g. write detailed clinical notes; call parents and guidance counselors; wait on hold with insurance companies for hours on end), and the fact that they are not paid to do any of these things. This often amounts to a 50-hour workweek or more.

So, the prelicensed therapist earns a gross $3000 each week from the insurance. Not bad! But they actually only keep $1500 of that, at best, and that has to be amortized over the 50 hours per week they actually worked, not just the 30 for which they could bill. That works out to about $30 per hour, pre-taxes—for a job that requires a master’s degree, and mainly involves you spending all day listening to people’s deepest traumas and grief. And because these practices generally don’t have a provision for paid time off, and in many cases not even for health insurance, you’ve got to factor those in as well.

Meanwhile, the owner-supervisor is pulling $50 per client session, $1500 per week, for doing essentially nothing. If they have ten prelicensed clinicians working for them (which is not at all unusual, some have many more), under the constraints above, that means they’re making about $72,000 per year off each clinician, for a total of $720,000. Now, that’s gross (in every sense), so their take-home is lower, but they’re still making top tax bracket money in exchange for doing ten hours a week of (as mentioned, usually shitty) clinical supervision and making sure that everyone does their paperwork.

This is frank exploitation, a clinical rentier state. It also has a significant adverse impact on the effectiveness of our social work workforce, because it means huge swaths of the next generation of clinicians are being trained by rapacious businesspeople, often quite clinically and pedagogically underqualified, acting primarily out of their own financial self-interest. This is a very bad educational setup, a form of what Tressie McMillan Cottom has called Lower Ed.

Lower Ed

Cottom’s landmark study of Lower Ed was concerned mainly with for-profit educational institutions in the United States. These institutions sprang up because a gap in public policy created an (often unforeseen) opportunity for someone to make money. Some of the major gaps include:

1. Publicly-funded student debt. Rather than just funding people getting an education, as most other industrialized nations do, the United States runs a colossal debt-financing scheme, whereby it’s quite easy to massively indebt oneself to the federal government in order to get one’s education. There are relatively few checks on how much money can be borrowed, and what it can be borrowed for.
2. “Credentialism,” which is Cottom’s term for the somewhat unusual way licensing and other systems of merit badging work in the United States. The state creates huge numbers of licensed professions, but it doesn’t do the preparatory work of training people for these licenses. Instead, in Cottom’s terms, they “risk-shift,” obliging people get personal loans to spend on their job training, which they often spend at for-profit educational entities that crop up to provide it. “Credentialism” also refers to the general sociological phenomenon by which ever more kinds of work either need a credential, or can be made to seem like they do by an entity that wants to charge you for providing the training for said credential.

Cottom’s interest is in for-profit higher educational institutions; what I want to argue is that we should see these private for-profit group practices as an as-yet unstudied part of the Lower Ed system. You see, social workers can’t actualize the benefit of our graduate degrees without two years of post-MSW supervised practice, at least not if our goal is to see patients clinically (which is notionally the most lucrative domain of social work practice). Psychologists, by contrast, get handed their diploma, take a (horrible) test, and they’re ready to practice independently. The state structures the social work profession in such a way that we need ongoing post-graduate continuing education, specifically in the form of clinical supervision, in order to translate our degrees into the remunerative license it’s supposed to confer. To be a clinical supervisor is to be a teacher; in principle, the essential reason that trainees work in these practices is because they have both an administrative and a substantive need to be taught.

In this light, we need to understand private group practices as educational institutions—for-profit, usually shitty ones, more closely resembling the privately-owned beauty schools Cottom studied than the nonprofit universities that (probably) granted the MSW. Of course, even this is changing; there has been an explosion of facially nonprofit universities contracting with third-party for-profit corporations in order to offer online MSWs to pad the university’s bottom line, as Cottom also notes. This is enshittenment upon enshittenment.

How comfortable would we be with a school that was structured in the following way?:

• The school is privately owned by its president, Professor Z (a title he has conferred upon himself). He also named the school: The Professor Z Center for the Advanced Study of Learning to Do Social Work Good.
• Professor Z is not just the college president, he is the chair of its only academic department: social work.
• Professor Z will provide all of your lessons for the two years you are enrolled; he’s providing all the lessons to all the other students, too.
• While you are enrolled at the Professor Z Center, you have to work in the Professor Z Institute for Really Good Therapy. Professor Z will keep most of the money you make from insurance companies for the therapy you do at the clinic, and he’ll accept that in lieu of tuition for the lessons he gives you in Really Good Therapy (RGT), which he insists is the treatment of choice for almost everything. If your own clinical judgment about the best interests of the patient (who he’s never actually met) differs from Professor Z’s, he has the legal authority to insist that you do it his way anyway.
• If you piss off Professor Z, he can refuse to sign the form that will allow you to get credit for all the work you did. You will earn no credit for the time that you spent at The Professor Z Center, and you will need to start again from scratch at another for-profit institution.

By Contrast . . .

I’ve saved this section for the end, because I’m reluctant to talk about my own supervision practice here, for fear of looking self-promoting. Still, I think it’s a useful contrast, so I’m including it, with the understanding that I hope you take it with a grain of salt, knowing that I can never fully mitigate my own inclination to fashion myself in a way that suits my interests as a small business owner. Capitalism, and all that.

I’ve been in the field of social work for 15 years. I have a MSW, a PhD, and a certificate (its own dubious credential, I hasten to add) in the kind of psychotherapy I practice, psychoanalytic psychotherapy. I’ve been a decorated faculty member at the masters and doctoral levels at three different institutions, two of them top ten programs in my field, and I’ve served as an assigned mentor to somewhere between dozens and hundreds of other teachers over the years, depending upon how you count. So, whatever my numerous flaws, I am not a fake expert, and I’ve had to demonstrate that I know how to teach.

I didn’t set out to become a clinical supervisor. Rather, my former students, and people who had read my scholarly work, sought me out for clinical supervision. In almost all of those cases, the trainee was working at a for-profit group practice where they felt increasingly uncomfortable with the quality of the clinical guidance they were getting from the owner-supervisor. Often, they were being incentivized, or frankly ordered, to do things they felt were not in the best interests of their patients. They came to me seeking a second opinion from someone without a dog in the fight, and they stayed because they were relieved to have the benefit of advice from someone who had no structural incentive to direct their clinical work in a manner that wasn’t in the best interests of the patient. Because they were paying me privately, I worked for them, rather than the other way around.

I earn substantially less money per hour from doing clinical supervision than I do from seeing patients, roughly 1/2 to 1/3 as much. I run what’s sometimes called a Robin Hood practice, where I charge a high standard rate to people who can afford it in order to underwrite other, less lucrative work—in my case, teaching at a public college and working with new clinicians as a supervisor, which is what I spend about 90% of my professional time doing. Doing clinical supervision is, strictly speaking, financially irrational for me. I do it because I find it incredibly valuable, both personally edifying and important for the overall health of the clinical ecosystem, and because it’s less emotionally draining for me than psychoanalysis often is.

If I were to start the Professor Carter Center for Excellence in Talking about Feelings for Money, and the math I laid out above obtained, I would be a millionaire within 2-3 years. It is probably very stupid of me not to do that, but I also didn’t get into this field to be a millionaire; I got into this field to do work I believed was meaningful, in exchange for a salary that let me buy fancy cheese sometimes without worrying about it too much. It suggests that there is something very wrong with the field that, for someone like me, it’s a lot easier to do the former than the latter these days.

Which gets at the other major public policy failure driving this shift towards private group practices—persistently stagnant reimbursement rates for psychotherapy. You see, the last thing insurance companies or the government want to do is spend more money on clinical services, so they just don’t. The rates paid to providers for psychotherapy don’t even keep up with COLA. What this means is that, once you’re a clinician whose paycheck comes from insurance companies, you have absolutely no way to ever get a raise unless the insurer incrementally raises everyone’s rates. Whether you’ve been in private practice for one year or thirty years, you’re earning the same $100 per hour, even as your own costs (including, perversely, for health insurance) are skyrocketing.

A setup such as this will inevitably create a lot of corruption. One form of corruption that is arguably ethically justified under the circumstances is insurance fraud, but that’s a discussion for another day. Other than sticking it to the insurers sub rosa, though, two basic options remain viable strategies for the clinician who wants or needs to give themselves a raise. One is to raise your rates on people who pay you privately, and hope that enough people see fit to do so to raise your bottom line (this is the path I’ve chosen, for my sins). The other is to find some people to work under you whose earnings you can garnish. As unsavory as I find these private group practices, they are a rationally self-interested response to a public policy environment in which mental healthcare is given shortest shrift, particularly when that context butts up against the problem of the exorbitant debt burden many therapists incur in order to become therapists.

Going Public

The solution, if there is one, involves going public. I mean this in two senses.

The first is a return to working for the public—whether via government agencies, nonprofits specifically oriented towards broad-based public service, or radical models of mutual aid and collective care.

The second is in the sense of broadcasting this dilemma publicly. While social workers should not assume everyone will care about our problems—many people would kill to earn $30 per hour instead of $7.25, whatever the work entails—we need to be better about pushing these problems into public view in order to build towards public pressure for public solutions. Increasingly, the general public is recognizing that our healthcare infrastructure is fundamentally broken and corrupted, and they are justifiably frightened by the thought of living in a society in which they cannot safely or reliably access care in a crisis. This reality is hardly news to poor people, of course, for whom it’s never been otherwise; still, realpolitik dictates that we should try to influence public opinion if it will enhance our ability to get the training we need to provide the care people need, without either the training or the work itself being so financially vitiating that it’s better just to do something else.