I think one point 1 the big thing depends on setting. I spent a good portion of my career working for other people in agencies and group practices. In those settings I didn’t really have those headaches because there was generally a “buffer”. If a collection needed to occur someone else handled it or if I had to I could at least deflect blame a bit. But the downside of working in those settings is that they take a lot of your money. Around here the standard split for private group practice is 40% to the group and most community agencies take 50-60%.
Those splits can sound high but they make sense for smaller groups in areas with high commercial rent. That said I’ve since shifted to telehealth and gone fully private with my own llc. This has significantly raised my income (almost doubled). But this creates major headaches because I no longer have that buffer. It can be heartbreaking at times to work with a client who is truly trying hard, struggling because of financial stress, and then having to tell them their card was declined. Or even worse, the insurance finally processed the last three sessions, it turns out their policy had lapsed, and they now owe you $360 plus another $120 for today. Do you shoulder the burden and eat those costs to help that person struggle a bit less? Tough call.
Other things in terms of idealism: the hourly rate is pretty decent. Around here a masters level clinician will get ~$85/38-52 minute session and ~$110/53+ min session. And you will likely have no shortage of clients; I’m always overbooked and I have a wait list through the end of December right now (which is the cap, I could easily just let it grow). BUT you are working with people with mental health issues. You will have people that no show. You will have people that cancel. Sometimes it’s the standard stuff like right now strep and RSV are going around or in a few weeks the holidays will happen. You will have people that enthusiastically begin services, tell you their life story, create a treatment plan, then disappear. Your earnings will become contingent on how well you can keep your utilization up. There will be weeks where you work a lot but you spend a lot of time doing things you don’t bill for; answering emails, doing new patient consults, etc. if you work with kids/teens this becomes much worse because you inevitably get parents that want to constantly check in. Your life becomes a balancing act of setting boundaries around this stuff. Do you just refuse to do it? Do you become the therapist that charges for every contact? Do you just give in and become the therapist that works 70 hours a week and gets paid for 30?
Practice ideals too: a lot of the day to day is way more frustrating than you can conceptualize. The ideal is someone comes in and says “I want to work on x” and then you do conceptualize the case and do that. But a shocking amount of people come in and say “I don’t know why I’m here”. Therapy can be so muddy and ill defined. In addition a lot of mental health issues are really sociological and economic issues masquerading as mental health issues and we’re often just not supposed to mention that which is frustrating. Like an employee who has a disability but the employer is being an asshole about accommodations will sometimes come to therapy to vent about the anxiety and frustration it causes. There’s nothing wrong with this person; they just work for an asshole. Or someone who is chronically anxious because they are poor. They might have actually mh issues but it’s really hard to tell with that financial stress constantly confounding everything. Etc.
You’ll certainly get the more annoying kind of harder too. People who push boundaries and email or text you 200 times a week. People who get really upset with you for challenging them a bit and freak the fuck out. People who make everything into a joke and never take anything seriously. People who talk over you and refuse to hear anything you say. People who refuse to honor your time limits and push past the end of session even though they know others are waiting. People who say nothing the whole time they are with you. People who text you to schedule an appointment, don’t respond when you reply asking what would work for them, and getting pissy that you didn’t track them down like you’re their parent.
Generally though in terms of “harder” clients you should be fine on the outpatient level as long as you have good boundaries. Outpatient is somewhat limited in level of severity that can be treated so if you’re encountering someone that’s actively suicidal/homicidal, someone whose health is compromised to the point of danger (eg severe eating disorder), someone whose lost touch with reality completely or is significantly delusional, etc you should be referring out to higher level of care. In outpatient your “harder” will almost always be the above
One last big thing from a practice point is the vicarious trauma thing. If you do trauma work it can be rough to hear the awful shit people have gone through. Although while this may sound callous it’s not always as rough as you would think. I’ve heard absolutely horrible stories of sexual assault, child abuse, etc, and they don’t really stick with me the way I worried they would. What sticks with me more is the day to day pessimism. Talking to people who are in depressive episodes all day for years can really fuck with you. Keep yourself in check, do your own therapy, self care, whatever it takes
Keep in mind the beginning of the career kind of sucks. The system is built to keep community mental health agencies afloat, at least on this side of the country. Don’t be surprised if you have to spend the first ~2 years post grad working for peanuts in an agency accruing hours for licensure. Your wages will go up significantly once this occurs, especially if you go telehealth only fully independent. And especially so if you work a lot. A great deal of therapists only work 10-20 client hours per week. I do more like 30-35, 6-7 per day. It’s not a particularly long day. 2 people, break, 2 people, break, 1-2 people, done. 8 hours with 2 hours of breaks. This is where I break from my colleagues a bit as a lot of my peers think this schedule is too much. I think they’re being a bit dramatic tbh. I also think this is why they complain about barely making 60-70k a year and I’m making well over six figures even with a pretty generous sliding scale. I don’t mean to brag, genuinely, but more to illustrate that you can make a solid living wage in this career if you work smart and put in the hours. It’s not an easy job by any means but at the same time what job lets you put in 20-30 hours a week and make six figures? That’s absurd. However, you can realistically put in an actual 40 and make a solid income with a potential for very good work life balance.
As for question 2 I think it’s mostly that I’m a bit bored. I’ve been doing clinical practice for over a decade now and it’s work that I enjoy but I find myself doing more stuff on the side. My projects on the side get more and more ambitious and I figure it would be nice to develop those skillsets more with actual connections. I’ve kept programming and doing a lot of microcontroller stuff since high school (which was 20 years ago, ugh) so I’ve gotten pretty decent but at the same time I’m sloppy in a lot of ways because I’ve never had a proper instructor or mentor. I think connecting with a proper work environment or maybe going back to school might help take me to a more serious level. I’d really like to be good enough to combine my programming skill with my research interests in behavioral psych and operant conditioning models. Although I’m sure there’s some 22 year old in the machine learning gold rush beating me to it lol
Sorry for the novel, I’m pretty chatty. hope this helps!