fervent anticapitalist here who is also a therapist and works in a therapy collective with a group of other folks. i see profit as the result of exploitation so would agree that in this model there is exploitation. part of how capitalism makes exploitation hard to see is that there is a lack of transparency around how much it actually costs to run a business. in our model, everyone shares in the cost of the expenses of running the practice, the person who is actually doing that work is compensated for it, and if we happen to have any profit left at the end of the year we decide as a group where that goes. therapist commission is capped so they pay no more than the cost to run the business and as a result everyone takes home a living wage. there are creative solutions! having said that...we are also in canada, and the the licensing process is different here, which has likely made this simpler to implement.
i'm not, i've never heard of that, we probably use some different directories in canada but i'm open to a chat for sure! I love the idea of worker co-ops!
We're not a co-op at this point, this is the first i've heard of therapy co-ops. i would love to see if we could move in that direction, but it would be up to the whole team. collective to us means a group of folks working collaboratively under the same umbrella while building their own caseloads...this means costs for operations (market/website, etc) are shared, taking off a lot of the pressure you face if you are solo. we also collaborate on case consultations and offer each other a lot of peer support, therapist burnout rates are really high and we are trying to combat that by creating space to learn and grow together
I think that’s how Phoenix operates. One LLC but everyone operates independently under it, manages all their practice stuff under it. The LLC is used to split expenses for office rent, EHR etc - I think. Their contact info is on the website if you wanna try out chatting with them.
“In this scenario, each of the 15 associates make $3200 per month, and $38,400 per year.
The owner is pulling in $120,000 per month and $1,440,000 per year in revenue *for the company.*”
Subtract payroll taxes, office rents for 15 people, supervision hours. And then depending on the state, 35-50% income tax. This is not a cash cow
Aside from the bad math, this is no different than the rest of the free market capitalism based businesses that exploit workers for the owners benefit, so maybe we should be debating Milton Friedman and Karl Marx??
Huh, I thought the math was good but now I'm rechecking and:
If the associates make 40/hr and see 20 clients per week, 40x20 = 800, 800x4 = 3200. The premise was avg insurance payout per associate is 100, and since 40 goes to the associate, there's 60 leftover in revenue. So, labor time from 15 associates x 20hrs/week x 60 = 18,000/mo in revenue which would be 216k/yr.
Not sure how I fucked that up so bad- will have to go edit it later thanks for catching.
Yes in probably part 3, unless it's part 2, there will be some exploration of neoclassical vs keynesian vs marxian economic thought. But I'm starting with capitalist realism and naming more thoroughly what neoliberalism is, the thing we're in, to then launch from there. There will be explorations of worker cooperatives, social democracy, some of yanis varoufakis' speculation about a better future (kind of anarcho-syndicalist), and how we get there. And considerations around whether the realm of private practice and the MH industry even has a place in that movement. Maybe it does, maybe it doesn't. Gonna let readers decide.
I also love a bit of a debate and enjoy pushing each other a bit to grapple with ideas like this.
To that end, I think you’re over-conceptualizing and theorizing this.
What gives it away is that you are actually really flattening your idea of who a therapist is or could be.
In my life, myself and many of my therapist friends are marginalized in multiple ways (many in my particular circle are disabled BIPOC folks). Many of us do not come from families with money but are working our asses off to get ourselves to better socioeconomic positions in life and sacrificed a lot to get there (I worked 2 jobs and held down an internship, and then worked 2 jobs and had an extremely exploited position at a small group practice while I had my limited permit).
You state, at one point, “who cares about some 2:1 ratio in some highly educated, professional, middle class American situation. Really, who cares?,” but you’re missing the demographic of marginalized people that I’m familiar with who barely made it out of school, internships, or limited permit jobs with our sanity. Not just because we made next to nothing and certainly barely enough to live off of, but because we were also often subjected to additional emotional labor in these spaces - whether being tokenized, discriminated against, given additional grunt work that our peers weren’t given…. One person I know literally was told that the place we were working wouldn’t sign off on their hours because they didn’t think they were ready (they were one of the smartest clinicians I knew) and forced them to work an additional month unpaid in order to get their hours signed off on… one of my friends is currently working on a visa as well and can only work for the practice they currently work for for the next two years.
One of the things you are making inadvertent assumptions about is the illusion of choice. You are less likely to be exploited when you can choose to leave or have options for something else, potentially better.
If we want to have a serious conversation about exploitation, we can’t remove these realities from what we’re talking about.
Exploitation happens on many levels, and more or less to different individuals in organizations based on social location, citizenship, perception of social location, respectability… it isn’t as simple as ratios or numbers.
Of course, I’m interested in your take on capitalist realism and I’m looking forward to reading the next parts of the series — I agree that there aren’t enough convos happening about this writ large (and in the overall landscape of therapy land) but I can tell you this was all my colleagues and I could grapple with while we were working thru our internships and limited permits.
Many of us ended up burning out from lack of support, working too many jobs to sustain ourselves, and unrealistic work loads at these practices.
In many ways, the lived experiences we’ve all had says enough for me.
I mostly just want whatever we can all get on the same page with to start demanding some changes, so whatever theories we need to use to help people understand work for me. 🤷🏼
Doesn't seem weird to me. Thank you. Like most human services workers, I have not carefully considered the big picture. It seems that the answer to your question, it sure looks like exploitation.
Definitely stay tuned for parts 2 and 3 (and maybe more)! I think readers / thinkers / therapists should absolutely be allowed to think it is or is NOT exploitation. Maybe a 2:1 ratio is absolutely fine. We need to understand what capitalism is more broadly and think that and related things through more.
I have just watched a younger friend go through exactly the process you describe. We have had brief conversations about her situation: too large caseload inviting burnout right out of the box….while the boss bags the money. I worked for a non-profit system and never gave money much thought, to my regret, because I was not paying attention to the pay grades scale. I woke up eventually and won three grievances against my employer or I’d be a greeter in Walmart at 85.
Excellent essay. To me, what you describe 100% is exploitation. Something you hint at is that the "relations of production" as identified by Marx. Capitalism's foundation is authoritarian relations of economic production. In that framework, a 2:1 income disparity is absolutely still exploitation.
I had this very experience as a pre-licensed therapist at a private practice. I was paid nothing yet they charged clients. The associates were to charge $140 private pay but only took home $44 of that (70/30 split). The place was super posh; upscale building, expensively and meticulously furnished. Thankfully I left and found myself in CMH with a director that lives in average housing and pays interns something and associates rather well for my area (70k+).
As the author mentioned, income disparity is a reality that is impacting humanity across the globe. I recently looked at the tag for my Victoria's secret bra, which read 'Made in Sri Lanka.' I'm sure the women working in those factories could never afford a $50 bra. It's like this with almost everything we buy - furniture, medicine, equipment, clothing, food, you name it. This whole thing works because we are exploiting other people for our benefit. I want a fair world where all of humanity can buy nice underwear, decent housing and afford health care. Although I will continue to vote for socialist values, I don't know if this vision is possible.
Thank you for posting this. We need to be having these discussions.
This is really a simplistic view of owning a business. There are MANY more considerations to take into account. To name a few: are their benefits, the increased liability of having pre-licensed clinicians, the training for them, the hours spent reviewing and signing paperwork, insurance audits, other forms of overhead(insurance, EHR systems, HIPAA compliant phone services, employment needs such as office furniture, electronics, play items if you see children etc) and sick time. This is not an exhaustive list. Not to mention 20 hours is half a typical work week. I would encourage you to consider a broader picture of what it takes to run an actual business.
Hi I read it- break up your paragraphs! Remember in my piece that I'm not saying there is exploitation going on necessarily. If one thinks capitalism is good, there's no exploitation. If one thinks a 2:1 or 3:1 ratio is not exploitative, it's not. If you're a socialist who thinks the socialist movement should focus on lots of other things, then whatever happens in group practices are consequential.
My main interest is launching us into parts 2 and 3 so we can examine different political economic orientations toward understanding labor exploitation more broadly, so we can circle back to see what we think. Because like I said, most therapists don't have any theory to draw on there except for capitalist realism which operates unconsciously for most.
fervent anticapitalist here who is also a therapist and works in a therapy collective with a group of other folks. i see profit as the result of exploitation so would agree that in this model there is exploitation. part of how capitalism makes exploitation hard to see is that there is a lack of transparency around how much it actually costs to run a business. in our model, everyone shares in the cost of the expenses of running the practice, the person who is actually doing that work is compensated for it, and if we happen to have any profit left at the end of the year we decide as a group where that goes. therapist commission is capped so they pay no more than the cost to run the business and as a result everyone takes home a living wage. there are creative solutions! having said that...we are also in canada, and the the licensing process is different here, which has likely made this simpler to implement.
are you listed on therapistworkercoops.info ?
in part 4 i might even wanna like... interview you maybe. it's gonna be about co-ops in the field, i think. if i stick to the series outline.
i'm not, i've never heard of that, we probably use some different directories in canada but i'm open to a chat for sure! I love the idea of worker co-ops!
So are you guys a worker co-op technically or nah? Like, what does 'therapy collective' mean more specifically?
We're not a co-op at this point, this is the first i've heard of therapy co-ops. i would love to see if we could move in that direction, but it would be up to the whole team. collective to us means a group of folks working collaboratively under the same umbrella while building their own caseloads...this means costs for operations (market/website, etc) are shared, taking off a lot of the pressure you face if you are solo. we also collaborate on case consultations and offer each other a lot of peer support, therapist burnout rates are really high and we are trying to combat that by creating space to learn and grow together
I think that’s how Phoenix operates. One LLC but everyone operates independently under it, manages all their practice stuff under it. The LLC is used to split expenses for office rent, EHR etc - I think. Their contact info is on the website if you wanna try out chatting with them.
That's very helpful! Thanks! It would be great to chat with someone else who is trying to do things differently :)
How does 15 x $3200 = $120,000???
(It’s $48,000).
“In this scenario, each of the 15 associates make $3200 per month, and $38,400 per year.
The owner is pulling in $120,000 per month and $1,440,000 per year in revenue *for the company.*”
Subtract payroll taxes, office rents for 15 people, supervision hours. And then depending on the state, 35-50% income tax. This is not a cash cow
Aside from the bad math, this is no different than the rest of the free market capitalism based businesses that exploit workers for the owners benefit, so maybe we should be debating Milton Friedman and Karl Marx??
Huh, I thought the math was good but now I'm rechecking and:
If the associates make 40/hr and see 20 clients per week, 40x20 = 800, 800x4 = 3200. The premise was avg insurance payout per associate is 100, and since 40 goes to the associate, there's 60 leftover in revenue. So, labor time from 15 associates x 20hrs/week x 60 = 18,000/mo in revenue which would be 216k/yr.
Not sure how I fucked that up so bad- will have to go edit it later thanks for catching.
Yes in probably part 3, unless it's part 2, there will be some exploration of neoclassical vs keynesian vs marxian economic thought. But I'm starting with capitalist realism and naming more thoroughly what neoliberalism is, the thing we're in, to then launch from there. There will be explorations of worker cooperatives, social democracy, some of yanis varoufakis' speculation about a better future (kind of anarcho-syndicalist), and how we get there. And considerations around whether the realm of private practice and the MH industry even has a place in that movement. Maybe it does, maybe it doesn't. Gonna let readers decide.
Um I think you’re both wrong?
“labor time from 15 associates x 20hrs/week x 60 = 18,000…”
Per WEEK.
So multiplied by say 50 (working) weeks a year is 900K revenue.
Oh crap I think you're right! The 18,000 in revenue is per week, and times 50 is 900k. Damn I have to edit the original piece again...
I appreciate this post a lot.
I also love a bit of a debate and enjoy pushing each other a bit to grapple with ideas like this.
To that end, I think you’re over-conceptualizing and theorizing this.
What gives it away is that you are actually really flattening your idea of who a therapist is or could be.
In my life, myself and many of my therapist friends are marginalized in multiple ways (many in my particular circle are disabled BIPOC folks). Many of us do not come from families with money but are working our asses off to get ourselves to better socioeconomic positions in life and sacrificed a lot to get there (I worked 2 jobs and held down an internship, and then worked 2 jobs and had an extremely exploited position at a small group practice while I had my limited permit).
You state, at one point, “who cares about some 2:1 ratio in some highly educated, professional, middle class American situation. Really, who cares?,” but you’re missing the demographic of marginalized people that I’m familiar with who barely made it out of school, internships, or limited permit jobs with our sanity. Not just because we made next to nothing and certainly barely enough to live off of, but because we were also often subjected to additional emotional labor in these spaces - whether being tokenized, discriminated against, given additional grunt work that our peers weren’t given…. One person I know literally was told that the place we were working wouldn’t sign off on their hours because they didn’t think they were ready (they were one of the smartest clinicians I knew) and forced them to work an additional month unpaid in order to get their hours signed off on… one of my friends is currently working on a visa as well and can only work for the practice they currently work for for the next two years.
One of the things you are making inadvertent assumptions about is the illusion of choice. You are less likely to be exploited when you can choose to leave or have options for something else, potentially better.
If we want to have a serious conversation about exploitation, we can’t remove these realities from what we’re talking about.
Exploitation happens on many levels, and more or less to different individuals in organizations based on social location, citizenship, perception of social location, respectability… it isn’t as simple as ratios or numbers.
Of course, I’m interested in your take on capitalist realism and I’m looking forward to reading the next parts of the series — I agree that there aren’t enough convos happening about this writ large (and in the overall landscape of therapy land) but I can tell you this was all my colleagues and I could grapple with while we were working thru our internships and limited permits.
Many of us ended up burning out from lack of support, working too many jobs to sustain ourselves, and unrealistic work loads at these practices.
In many ways, the lived experiences we’ve all had says enough for me.
I mostly just want whatever we can all get on the same page with to start demanding some changes, so whatever theories we need to use to help people understand work for me. 🤷🏼
There's a lot of good stuff here, thanks. I wonder if you might want to write your own piece about this and get it circulating around.
I’ve definitely thought about it! Probably eventually!
Again - definitely looking forward to reading more and having more to chew on.
A few clarifications:
1) “one of my friends is currently working on a visa as well and can only work for….”
This doesn’t mean they only have 2 years left… it means they can’t *leave* this practice for the next 2 years, even if they wanted to.
2) “Many of us ended up burning out from lack of support, working too many jobs to sustain ourselves, and unrealistic work loads at these practices.”
I should have also added emotional labor, transphobia, discrimination.
Doesn't seem weird to me. Thank you. Like most human services workers, I have not carefully considered the big picture. It seems that the answer to your question, it sure looks like exploitation.
Definitely stay tuned for parts 2 and 3 (and maybe more)! I think readers / thinkers / therapists should absolutely be allowed to think it is or is NOT exploitation. Maybe a 2:1 ratio is absolutely fine. We need to understand what capitalism is more broadly and think that and related things through more.
I have just watched a younger friend go through exactly the process you describe. We have had brief conversations about her situation: too large caseload inviting burnout right out of the box….while the boss bags the money. I worked for a non-profit system and never gave money much thought, to my regret, because I was not paying attention to the pay grades scale. I woke up eventually and won three grievances against my employer or I’d be a greeter in Walmart at 85.
Excellent essay. To me, what you describe 100% is exploitation. Something you hint at is that the "relations of production" as identified by Marx. Capitalism's foundation is authoritarian relations of economic production. In that framework, a 2:1 income disparity is absolutely still exploitation.
I had this very experience as a pre-licensed therapist at a private practice. I was paid nothing yet they charged clients. The associates were to charge $140 private pay but only took home $44 of that (70/30 split). The place was super posh; upscale building, expensively and meticulously furnished. Thankfully I left and found myself in CMH with a director that lives in average housing and pays interns something and associates rather well for my area (70k+).
As the author mentioned, income disparity is a reality that is impacting humanity across the globe. I recently looked at the tag for my Victoria's secret bra, which read 'Made in Sri Lanka.' I'm sure the women working in those factories could never afford a $50 bra. It's like this with almost everything we buy - furniture, medicine, equipment, clothing, food, you name it. This whole thing works because we are exploiting other people for our benefit. I want a fair world where all of humanity can buy nice underwear, decent housing and afford health care. Although I will continue to vote for socialist values, I don't know if this vision is possible.
Thank you for posting this. We need to be having these discussions.
This is really a simplistic view of owning a business. There are MANY more considerations to take into account. To name a few: are their benefits, the increased liability of having pre-licensed clinicians, the training for them, the hours spent reviewing and signing paperwork, insurance audits, other forms of overhead(insurance, EHR systems, HIPAA compliant phone services, employment needs such as office furniture, electronics, play items if you see children etc) and sick time. This is not an exhaustive list. Not to mention 20 hours is half a typical work week. I would encourage you to consider a broader picture of what it takes to run an actual business.
Which part that I wrote is simplistic?
hi, enjoyed the post, I appreciated the attempts for impartiality and taking different sides into account.
I was inspired to jot down a few alternative points of view
https://quirkypsychoanalyst.substack.com/p/some-things-to-have-in-mind-in-group
I hope this inspires more and more thoughtful discourse.
Cheers,
Roman
Hi I read it- break up your paragraphs! Remember in my piece that I'm not saying there is exploitation going on necessarily. If one thinks capitalism is good, there's no exploitation. If one thinks a 2:1 or 3:1 ratio is not exploitative, it's not. If you're a socialist who thinks the socialist movement should focus on lots of other things, then whatever happens in group practices are consequential.
My main interest is launching us into parts 2 and 3 so we can examine different political economic orientations toward understanding labor exploitation more broadly, so we can circle back to see what we think. Because like I said, most therapists don't have any theory to draw on there except for capitalist realism which operates unconsciously for most.