The Grad-School Class That Wasn’t Offered
My graduate education in social work laid the theoretical and practical framework of nearly every client session that would follow. I learned to build therapeutic rapport, assess and monitor symptoms, identify client’s strengths, improve overall functioning all while understanding the environmental framework and therapeutic relationship. What I didn’t learn? How to bill for any of it.
I never learned to run a practice, negotiate a contract, or even collect a client bill. In a cohort of mostly women, we were taught to elevate service above self-interest, dedicating ourselves to some of the most vulnerable populations, often at the expense of our own financial security. Therapy has real value for clients and clinicians alike, but the practitioner has historically not defined that value in economic terms, largely due to the training and culture of the profession. Now that’s changing.
In the immediate wake of COVID, demand for mental health treatment surged, stigma declined, and therapist waitlists grew. With startup costs so low, often little more than a professional license and a Wi-Fi connection, independent teletherapy practices multiplied, and outside industries took notice. That surge has since begun to taper off, but private equity remains firmly in the space.
Private equity, bringing capital and promise of efficiency and profit, sees therapy as an industry to be optimized: consolidate practices, scale clinicians, maximize patient revenue. For therapists with no experience in entity formation or strategic planning, leveraging the resources of private equity has significant benefits: scale mental health care, streamline operations, expand access, increase patient volume, and drive profitability. There are real advantages, broader marketing reach, increased access to care, stronger negotiated insurance contracts, and the ability to hire and grow quickly.
But Therapy is Nuanced
Unlike a fast-casual restaurant chain, psychotherapy is not a precise or optimizable process. Even the most seasoned therapist does not know exactly what will unfold when a new client walks into their office. Healing is not linear and our patients sit on a couch, not a conveyer belt. What we consider a therapeutic success is also financial failure: the client successfully meets goals and graduates from therapy.
Since I started my group private practice, I have expanded our services, added an integrated medication side to the business, hired more therapists, promoted others into leadership positions and created administrative roles. To meet the needs I saw, I had to scale my business, and in doing so, attracted the attention of private equity. What they offer is attractive: higher reimbursement rates, lower costs, upfront cash. However, I find myself asking: at what cost? Because the same system that rewards efficiency often overlooks what cannot be measured as easily, which is clinical presence, earned trust, therapeutic holding and genuine relationships, the very elements therapy depends on. When we begin to optimize it, we risk stripping it of the very conditions that make it effective.
When practices are built to maximize returns, something subtle but profound shifts. Clinicians feel it. Patients feel it. Instead of being about people, it’s about profit. So it is unsurprising when we consider that nearly one in five patients drop out of treatment prematurely because something about the system is not keeping them.[v].
Efficiency is not neutral. It reshapes what we value. Therefore, my practice is intentionally and unapologetically inefficient. It’s not efficient to provide multiple outreach attempts to the same new mother potentially interested in becoming a client, but it's good care. It is not profitable to waive the cancellation fee when a mom cancels at the last minute because her baby is sick, but it’s the right thing to do. It’s not profit-driven to own a small business that offers comprehensive benefits and retirement matching, but it’s an investment in our staff and their well-being. It’s hard to quantify a person getting better, but that’s the primary metric of good therapy.
Motherhood: The Ultimate Break Down in Efficiency
I work with mothers who are struggling in the perinatal period. Postpartum depression forces a mental and physical slowing. Perinatal anxiety is paralyzing and counterproductive to productivity. Rage drains a new mom’s energy without producing anything to show for it. The loss-informed transition to motherhood reveals how often we confuse output with well-being.
Our therapy rooms are increasingly filled with the pathology of productivity, where the demands to do more clashes with the realities of care, dependency, and human limitation. We abandon the idea that efficiency is the measure of success in favor of tenderness, presence, and compassion. We know that healing takes time.
In therapy, a new mom begins to unpack why she feels a relentless pressure to achieve. She starts to see that motherhood can’t be made efficient, and that being productive doesn’t guarantee success. Rest and pleasure doesn’t create anything you can measure. The luxury of sleeping when your baby sleeps doesn’t translate into time well-spent when the laundry is piling up. While there is notable evidence that suggests self-compassion enhances connection and decreases symptoms of depression,[i] the overwhelming consensus is that self-compassion is self-indulgent, weak and undermines motivation.
Her suffering comes from the expectations to fulfill the demands of her new role and her loss comes from not knowing who she is if she is not accomplishing. Despite an ingrained pull toward productivity, efficiency, and quick resolution, motherhood demands something else entirely: presence and patience. In motherhood, the logic: work harder, succeed faster quickly falls apart. And if that logic fails in the most intimate work of caregiving, it has no business being the standard of care in our mental health settings.
Healing at Her Pace
I spent years in classrooms, therapy spaces, supervision, and clinical training learning how to deepen my therapeutic work. I was trained to understand that meaningful and enduring change happens through the depths of human relationships. Honoring the dignity and worth of the person means sitting unhurried with the client in front of me. My competence and integrity require ongoing learning and reflection, for which there are no shortcuts or productivity metrics. I could be the most skilled therapist in the room, but that doesn’t make the therapy move faster if the client isn’t ready. Healing unfolds at the pace of the client and the steadiness of her provider. The work is careful, relational, and grounded; rushing this process would come at great cost.
When efficiency is the primary measure of success, the system may appear to expand while quietly eroding the very conditions that make mental health care effective. We are more likely to see therapist burnout and talented clinicians leaving the field entirely. This disrupts the therapeutic relationship, and clients are more likely to drop out of treatment prematurely.
Inefficiency as a Feature, Not a Flaw
I often think back to that classroom of women learning how to care for others. None of us were taught how to run a business. Perhaps that was the point. Because who could imagine we would one day be competing with private equity firms for ownership of the work we loved? We were trained to serve, not to extract value. But service alone cannot protect a profession. Social work has long depended on the assumption that those who care deeply will accept less in return. But care is not a weakness; it is the foundation of raising children. If we want mental health care to remain human, relational, and grounded in dignity, then we must protect the systems that allow it to remain so. When care becomes just another industry to scale, there is a price to be paid. That’s why in my practice, we have made inefficiency as our feature, not our flaw. We hope the rest of the field will follow.
[i] Neff, K. D. (2023). Self-compassion: Theory, method, research, and intervention. Annual Review of Psychology. Advance online publication. https://self-compassion.org/wp-content/uploads/2022/06/Psych-Review-article-in-press.pdf
References:
Frank, T. (2016). Listen liberal: Or what ever happened to the party of the people? New York, NY: Metropolitan Books.
Frost, R. O., Heimberg, R. G., Holt, C. S., Matt, Hewitt, P. L., Flett, G. L., & Mikail, S. F. (2017). Perfectionism: A relational approach to conceptualization, assessment, and treatment. New York, NY: Guilford Press
Furr, Nathan, et al. “It’s Time to Reimage Scale.” Harvard Business Review, 22 Nov. 2024, hbr.org/2024/11/its-time-to-reimagine-scale
Leichsenrignt, F., Sarrar, L., & Steinert, C. (2019). Drop-outs in psychotherapy: A change of perspective. World Psychiatry, 18 (1), 32-33. doi:10.1002/wps.20588
Neff, K. D. (2023). Self-compassion: Theory, method, research, and intervention. Annual Review of Psychology. Advance online publication. https://self-compassion.org/wp-content/uploads/2022/06/Psych-Review-article-in-press.pdf
Pokorski, E, et al. “The Impact of Social Pressure on High-Income Working Mothers in Academia” Journal of Public Health Issues and Practices, vol. 8, no. 1, 2024 https://gexinonline.com/uploads/articles/article-jphip-224.pdf