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.