What do counselors do when not seeing clients?
I often hear this question after friends, family, or acquaintances ask me about the business side of being a counselor. It usually goes like this:
Friend: "Wow, so your hourly rate is $100 per hour. I wish I made $100/hour."
Me: "Me too."
Friend: "But you do."
Me: "Not really. After you factor in continuing education, bookkeeping, taxes, notes, insurance billing, taxes, consultation, case management, and other non-billable activities along with overhead expenses, it's not nearly that."
Friend: "Oh so how many clients do you see a week?"
Me: "Perhaps 12-20, depending on the week."
Friend: "Oh.. what do you do with the rest of your time?"
That's when I start telling the story that I will tell you today. What goes on in the secret lives of counselors?
Activities shared by most mental health folks
There are some things all mental health practitioners have to do outside of seeing clients. Most of these are shared by all counselors whether in private practice or employed but some are only for folks who are self-employed.
This probably sounds trivial to folks not in mental health or perhaps outside healthcare in general but scheduling takes up a lot of time over the course of our careers. First, we set our schedules based on the demands of our personal and professional lives. We determine which days we want to/need to work, what times fit the other demands on our schedules, when our office space(s) are available, and when our clients can see us. Both we and our clients get sick, take vacations, and have life changes that require us to change appointment times. This one has been on my mind recently because I've been making major changes to my schedule to accommodate my son's new school schedule starting in September, and it's taken hours of time to get clients into times that I think will work long-term. Managing our schedules is also important in that we have to figure out what times and days we're most likely to be high-performing for our clients. When are we sharpest? When are we most empathic? Those are our ideal times to work.
We are legally required to keep medical records on our clients about the treatment they've received from us and what money has exchanged hands between us. I have a very lightweight system that is entirely paperless, allows clients to complete questionnaires using HIPAA compliant medical records systems, and minimizes time for me to complete documentation. It still takes approximately ten minutes per office visit to complete records of the visit and associated billing and payment documentation.
Not everyone does their own insurance billing but many of us with small practices do. In addition to the ten minutes mentioned above, filing an insurance claim on behalf of our clients takes an extra two or three minutes and once payment comes in, it can take up to five minutes to reconcile each claim. Those of us who are in network with insurance companies may be asked for medical records when companies perform audits and typically the time that it takes to compile and send those records, we cannot bill for.
Counselors often coordinate with other medical providers such as medical doctors, naturopaths, acupuncturists, prescribers, and sometimes family and community members, to further our clients' mental health. This time is often non-billable to insurance companies and most of us don't charge clients unless it's a particularly complicated issue outside the norms of our practices.
At any given time, most of us mental health folks have at least one person in crisis with whom we are staying in closer contact than once a week. Sometimes this work is billable but most often it's not. It's part of providing good care.
Most of us do not rent space in Class A buildings (like the big fancy high rises in downtown). Many of us have to do our office space housekeeping ourselves. It may only take 20 minutes a week, but it's overhead.
If you're an individual practitioner, you have to do your own bookkeeping, taxes, marketing, advertising, client screening, and in counseling, referring prospective clients who do not fit your practice, to other mental health providers. I know I spend at least two hours a week providing referral services to folks who call or email my practice but whom I cannot work with personally, to other colleagues.
I read approximately one hour a day on professional subjects, in addition to attending continuing education courses both in person and online. I do this to maintain my license and also to learn new skills to help my clients. My choices of continuing education are almost always based on trying to help a client who I feel needs a new approach that I am competent to offer but need some more knowledge about or practice delivering.
Many counselors in private practice are "part-time," which can mean seeing anywhere from five to 24 clients per week. There is no absolute definition of "full-time" but my personal definition of full time counseling is 25 or more client contact hours a week in private practice, given the overhead required to maintain that practice.
Many counselors I know do some other paid work in addition to counseling. One of my friends helps run their family business. I've done technology consulting. Some folks I know do social justice advocacy work and sometimes get grants to do it. I'm currently writing a workbook for individuals who need career guidance. Side gigs offer two benefits: 1. They can bring in an extra stream if income and 2. they give you an outlet to meet people while working. The fact is, counselors can't be friends with their clients and sometimes it's nice to do some work where you can be friends with your clients and colleagues, hence doing non-mental health work part-time.
Probably largely because I am a mom and a counselor, I know a lot of other parent-counselors who spend part of their time doing counseling work and part of their time caring for young children.
Counseling requires many of the same skills as parenting. I'm not comparing my clients to young children, of course! It's just that holding space for someone who is vulnerable and having a hard time is something we're trained to do as counselors and that we have to do (however imperfectly) in parenting our children as well. On one hand, being a parent can enhance your ability to be a counselor by forcing you to practice your clinical skills when exhausted, personally challenged, and not your best. On the other hand, since it uses some of the same "mental muscles," I often see parent counselors working part time when financially possible, in order to allow themselves enough rest time to do a good job of both roles.
House and hobbies
Many of you know that I have an office based out of an ADU on my property. Therefore, keeping my house maintained and my yard well kept is both a personal and professional pursuit. Today I spent my entire "day off" reengineering the drip-line irrigation system - something I hope will keep me from the endless hours of hand-watering I did over this last 100 degree weekend, when the lines weren't working correctly.
I notice many of my counselor-friends have hobbies like gardening, cooking, or building/making things with their hands. Having very realistic, tangible hobbies can be a relief from occupational stress, "practicing what you preach," to clients who need stress relief. In other cases, some of us are "kinesthetic thinkers" and do our best thinking about client issues when moving our bodies.
Nutrition and Health
Physical health has a large impact on psychological health so it's probably no surprise that counselors can be real health nuts and foodies. Some have adopted particular styles of eating due to ethical and global environmental concerns. I have met more vegans and learned more about plant based diets since becoming a counselor than before I entered this profession. Others are on a relentless quest to experiment on themselves to find nutritional solutions to mood problems (for the record, nutrition is NOT in our scope of practice but since many clients present to counseling wanting to avoid medical treatment for their challenges, we like to be aware of many treatment approaches so we can refer to professionals who can help.). My interest in nutrition and food is more about culture and how our relationships with and around food influence our mental health. Rather than focusing on the food itself, I like to help my clients frame cooking for themselves and their loved ones as self-care. Or perhaps for someone who is struggling with their relationship with food, help them eat mindfully and pay attention to their body's cues on taste, hunger, and fullness. Food can be good medicine for mental health conditions, even if it's the behavior around food rather than the food itself that actually changes.
Counselors work very hard to have an impact on improving healthcare and social problems. The truth is, we're new to the medical establishment and have little power compared to physicians, hospitals, and insurance companies. That said, we're very squeaky little wheels. In Oregon, we have several mental health associations, each with their own lobbyist in Salem. Nationally, each of our major professional organizations fights hard for license portability, coverage of mental health conditions as any other medical condition, and other ways to increase mental health access and funding. Sadly, sometimes psychologists, psychiatrists, prescribing mental health nurse practitioners, counselors, and social workers fight between groups but mostly, it's pretty collaborative and usually disagreements are the result of good debates on scope of practice issues. Most counselors contribute in some capacity to activism. My personal focus is on educating the private sector on how to improve the health of their employees. I also try to help the counselors political action group when I can.
Some of my colleagues do amazing grass roots work, going directly to the public to educate, support, and improve access to mental health care. You'll see them at local farmers markets, rallies, and community events with big signs indicating they are mental health practitioners there to provide information.
So are they like everyone else?
Yes and no. Any given counselor who practices part time probably has a private life that looks, from the outside, a lot like anyone else's. However what I think folks should know is that mental health professionals often find ways of integrating their professions into many other aspects of their time when not seeing clients directly. It's difficult to hear the challenges and sometimes systemic injustices suffered by our clients and not try to do something about it, most of your waking hours. Whether it's that we're on call because our clients often have our 24/7 contact information, or because we're trying to fix broken things about the world to make it a mentally healthy place, being a counselor isn't a hat that we can take off when we're not actively counseling people. So even if it doesn't always look like we're working (especially us "part-timers,") we might be.