Why I 'Broke Up' With Managed Care (Part 2)

Several months ago I wrote a post titled, "Why I Broke Up With Managed Care" that stirred up some passionate discussion! While I understand that it's not the route for every private practitioner, I have continued to build a private practice free of managed care and recently hired my 12th therapist.

While we don't bill insurance directly, we do give a superbill to clients so they can seek reimbursement from their health insurance so they can still use their benefits. As I've continued to write this blog, I've come across several therapists who have also "broke up" with managed care and asked them why they decided to build a fee-for-service therapy practice. Here's what they had to say:

Increased Reimbursement Rate

I've been in private practice for over 15 years. So, I experienced the first major transition of health care to "managed" care. I had friends and colleagues who began working in the managed care industry, and it quickly became clear to me that despite all the rhetoric about the necessity for evidenced-based care (which can be a very useful model of care), managed mental health care was really about making corporate the work of individual psychotherapists.

I also did the math. The last time I checked, insurance reimbursement was the average rate charged by psychotherapists in the 1980s. Today, I can afford to have two additional office hours available for new clients, by taking just one fee-for-service patient. This also allows me more discretion in seeing clients who are needing a low fee. Will Courtenay, PhD, LCSW "The Men's Doc"

Control Over Therapeutic Work

I wanted the freedom to determine, along with parents, the course and length of treatment and felt managed care would impede on that. Pam Dyson, LPC, RPT

My training is in social work, which is the source of the old adage "start where the client is at." That's my barometer for treatment, not where an insurance company believes my client and I should start or end our work. Will Courtenay, PhD, LCSW "The Men's Doc"

Increased Client Commitment to Therapeutic Process

Being a Christian counselor, by law I cannot bill insurance, even if I could I think private pay gives each person responsibility in the therapeutic efforts. When people  have to pay it makes them take their  therapy more seriously. Natalie Davis

No Diagnosis Required

My services are specialized in that I will work with children as young as three, something many therapists in my area will not do. The problems child clients present with are often not clinical but rooted in the parent-child relationship. I feel strongly that young children do not need a diagnosis on their permanent health record. Pam Dyson, LPC, RPT

More Time With Clients (Less Time Doing Paperwork)

I had worked in a managed care setting in the past, and I decided that in my practice that I want to avoid the incredible amount of paperwork, defending sessions, and over-diagnosing.  I also think it provides clients with more privacy. Sara Levitsky, LMSW, Birmingham Counseling For Women

Paperwork was the other major decision (in building a fee-for-service practice). I put a great deal of time and energy into my work with clients outside of our scheduled hours, including receiving professional consultation on a consistent basis. I have no time or patience for administrative busywork. Will Courtenay, PhD, LCSW "The Men's Doc"

More Flexibility To Offer Reduced Fees

Like Dr. Courtenay mentioned earlier in this article, when his practice is doing well financially, he has more (not less) time to devote to seeing clients at a reduced fee. I have found the same to be true. As my practice grows I am able to offer more free community workshops and do more pro bono work.

Do you run a fee-for-service mental health therapy practice? What led to your decision?

Adventures In Private Practice: Play Therapist Pam Dyson, LPC, RPT

"I provide practical solutions to child behavior problems," says Pam Dyson, LPC, RPT of St. Louis. What parent couldn't use some practical solutions?

As a child development expert, parenting coach, licensed professional counselor and registered play therapist, Dyson is clear about her mission to help children and families through play therapy and parent coaching. Learn more about Dyson's private practice journey, how she manages the ebb and flow of income impacted by the school year sessions, and how play plays a role in her own self-care.

Why did you decide to open a private practice?

I entered graduate school in mid-life with the goal of opening a private practice. Having been an early childhood educator for many years I knew there was a need in my geographic area for a therapist specializing in working with children 3-10 years of age.

I knew how to reach my target audience and I knew there was a market for additional specialized services such as consulting and coaching.  I also wanted the freedom to set my own hours. I knew that only by having my own practice would I be able to achieve all of those goals.

Clients that therapists find to be the most "difficult" are sometimes the ones who can teach them the most. What have you learned from your toughest clients?

Young children with challenging behavior problems try the patience of parents and caregivers and can be challenging for therapists. The younger the child, the less they have the ability to express their feelings and their needs.  Play therapy gives a child the freedom to express their feelings through toys and play materials.

By being with a child and observing their play I gain an understanding of what the child needs. Once a child is heard and understood we can begin implementing strategies to meet the child’s needs and overcome challenging behaviors.  Understanding the child from the child’s perspective is the key to the process.

What's your biggest pet peeve about private practice?

The unpredictability of steady income. There are cycles when I’m busy and when I’m not.  Mine is related to the school year. When school is not in session during the summer and holiday breaks children are not being brought to therapy. My busiest times of year are in the fall after school starts and after the winter break. I supplement my income with consulting services to schools and other professionals, parent coaching and play therapy training to mental health professionals.

How did you discover or develop your practice "niche"?

I was an early childhood educator before I became a therapist. When I enrolled in graduate school I knew I wanted to work with children using play therapy. I took course work related to counseling children, completed an internship at an agency specializing in child therapy and attended seminars and workshop specific to play therapy. Once I was licensed and opened my practice I already had a solid skill base as a play therapist. Having been a teacher I also had the skills necessary to work collaboratively with parents. It was a natural fit.

What resource (book, website, person) helped you the most when setting up your private practice?

I stumbled across an article by Lynn Grodski in Psychotherapy Networker Magazine that inspired me to pursue private practice. I felt she addressed my questions realistically so I read more of her writings and subscribed to her email newsletter.

What has surprised you most about being in private practice?

How much I enjoy every aspect from seeing clients to paying the bills. I anticipated not enjoying the routine, mundane tasks but I take pride in overseeing every detail.

Has your private practice helped you grow professionally? How so?

I’ve gained a lot of experience as a play therapist and two years ago I put those skills into training other therapists in the modality of play therapy by founding the St. Louis Center for Play Therapy Training.  As an approved provider of continuing education for the Association of Play Therapy I offer training opportunities for mental health professionals who are pursing credentialing as a registered play therapist.  As word of the quality of my trainings has spread I’m receiving requests to bring play therapy training to locations across the country.

Has it helped you grow personally, too? How so?

I’ve gained a lot of self-confidence not only in my ability to provide quality therapeutic services but in my ability to manage the business side of my practice. Presenting at conferences and seminars has helped me develop public speaking skills.

Being a therapist can be emotionally exhausting. What do you do to care for your own emotional and psychological health?

When I lock client files in the file cabinet at the end of the day I symbolically lock away my emotional connection to them as well. It ensures I don’t take my work home with me. I make it a priority to do things that are fun and playful such as listening to music, going to concerts and making handcrafted items. It would be challenging to be an effective play therapist if I didn’t make time to play.

How do you cope with the inevitable stressors involved with being your own boss?

I handle all of the day to day details of my practice myself. I’m a very organized person and I rely on to-do lists. While it’s time consuming it’s not overwhelming.  I network with other private practice therapists for support and encouragement regarding the challenges of private practice.

What personal strengths have helped you succeed in private practice?

Growing up on a farm in Kansas helped me develop a strong work ethic.  I’m not afraid to push up my sleeves and tackle whatever needs to be done in order to be successful.  My social skills are strong so networking and marketing come easy to me.  I also have a lot of self awareness and recognize that growing and maintaining a private practice is a process that takes a lot of patience and perseverance and that I sometimes need to reach out to my peers for support and encouragement.

To learn more about Pam Dyson's private practice visit

If you'd like to be featured in "Adventures In Private Practice Column" please submit a practice summary, and answers to the above questions here.