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12. Called to...Money, Money, Money (BBHMM)
10 Plays7 days ago
The business of being a mental health practitioner running your own private practice is something that we see people discuss on social media, but these conversations are often lacking in nuance. Many of the general public think therapists just want to take your money, but don’t know much about what goes on behind the scenes, both emotionally (how do we reach the people who can’t afford to see us?) and financially (how do we price our services and what’s the deal with insurance?).
Mentions in this Episode
Book: Surviving Autocracy by Masha Gessen
Game: Metaphor: ReFantazio by Atlus
Additional Notes
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Music: Calypsonian by Eshi Era (Standard License) Check out their Artist Profile here: Eshi Era
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Transcript
Intro
Introduction and Liberation in Mental Health
00:00:17
Ksera Dyette, Psy.D. (she/her)
Hello, everybody. Welcome back to Called to Healing. i am Dr. Ksera Dyette licensed clinical psychologist and also psychologist committed to building practices that are rooted in liberation so that we can take down this madness that we consider the mental health field. And I have with me
00:00:40
Blanca Torres, LMFT
Hi, I'm Blanca Torres. I'm a licensed marriage and family therapist in Nevada, and I'm committed like Ksera is too, but I'm a therapist currently in the middle of plotting my escape from faci$sm
00:00:52
Blanca Torres, LMFT
So ah we are coming as we are today.
00:00:57
Ksera Dyette, Psy.D. (she/her)
Yes, and as we usually do every single time.
Government Shutdown and Social Benefits Impact
00:01:00
Ksera Dyette, Psy.D. (she/her)
And as always, um i want to acknowledge that we are settlers, occupiers on stolen land here in Turtle Island in our respective states.
00:01:12
Ksera Dyette, Psy.D. (she/her)
um And we are constantly thinking about what liberation looks like in this hellscape that we are in.
00:01:25
Blanca Torres, LMFT
Indeed.
00:01:25
Ksera Dyette, Psy.D. (she/her)
Whether for ourselves personally or the people that we work with. um And ironically, or maybe not so ironically, we're talking about money, money, money, money today.
00:01:40
Ksera Dyette, Psy.D. (she/her)
And we usually set the context for our episodes since we are typically releasing them slightly later than they're recorded. And right now, kind of aligning with this timing, we are in the middle of an ongoing government shutdown.
00:01:55
Ksera Dyette, Psy.D. (she/her)
um
00:01:56
Ksera Dyette, Psy.D. (she/her)
where maybe, according to current news reports, there is some end in sight.
Autocracy and Accepted Lies
00:02:03
Ksera Dyette, Psy.D. (she/her)
um Obviously, it's been heavily politicized.
00:02:07
Ksera Dyette, Psy.D. (she/her)
um And when you go to that orange head man's website, it says Democrats have shut down the government, which is just not an accurate way to put people fighting to make sure that we actually have our rights.
00:02:20
Ksera Dyette, Psy.D. (she/her)
Yeah. And obviously food benefits have been played with with SNAP and it's just disgusting. There's just no other way to put it um that we are willing to allow people to starve for this fasci$t nonsense.
00:02:41
Ksera Dyette, Psy.D. (she/her)
I can't think of words because it's just so insane. It's so insane. Pardon the language.
00:02:46
Blanca Torres, LMFT
It is.
00:02:47
Ksera Dyette, Psy.D. (she/her)
Yeah.
00:02:48
Blanca Torres, LMFT
Yeah.
00:02:48
Ksera Dyette, Psy.D. (she/her)
yeah
00:02:49
Blanca Torres, LMFT
I mean, I feel like that's the only appropriate use of that word, and you know, right? Because I would never use that to describe someone going through a mental health crisis ever. so like, what else can you call what's happening?
00:03:02
Ksera Dyette, Psy.D. (she/her)
Yes.
00:03:03
Blanca Torres, LMFT
It's certainly quite a time to be alive.
Political System's Impact on Therapy
00:03:06
Blanca Torres, LMFT
And I don't know. It reminds me, there's this book called so the Surviving Autocracy by Masha Gessen. And in that book,
00:03:15
Blanca Torres, LMFT
they discuss one of the ways autocracy, I guess, bubbles or maintains itself, whatever, is that they state lies so boldly that they just, like, become...
00:03:35
Blanca Torres, LMFT
the truth people believe.
00:03:38
Blanca Torres, LMFT
And so it's objectively untrue that the Democrats are causing the shutdown. And yet they state it so loudly and so boldly that it's just somehow become,
00:03:49
Blanca Torres, LMFT
the reality is just basically their the distorted use of language. um you know But great book if someone wants to check it out.
00:04:02
Blanca Torres, LMFT
Surviving Autocracy, Marsha Gessen. It's a non-binary author from Russia, I believe.
00:04:10
Ksera Dyette, Psy.D. (she/her)
i'm Sorry, mean to cut you off twice. i apologize.
00:04:13
Blanca Torres, LMFT
You're good. You're good.
00:04:15
Ksera Dyette, Psy.D. (she/her)
ah But yeah, um and just to be clear, like Blanca and I are not just like this party, that party. That's not like the way we think about the political system.
00:04:26
Ksera Dyette, Psy.D. (she/her)
um We're just stating a series of facts about what is happening right now. um And it's important to be clear that like we interrogate everything that goes on both parties, backroom dealings, all of these different things that have always been true in the functioning of how the government has worked um in this country.
Financial Challenges in Therapy Practices
00:04:48
Ksera Dyette, Psy.D. (she/her)
So i just want to be, I want to state that clearly as a part of this conversation.
00:04:50
Blanca Torres, LMFT
yeah
00:04:53
Ksera Dyette, Psy.D. (she/her)
you
00:04:54
Blanca Torres, LMFT
Yeah, don't walk away thinking we're Democrats or anything like that.
00:05:01
Ksera Dyette, Psy.D. (she/her)
if you
00:05:01
Blanca Torres, LMFT
That's offensive.
00:05:02
Ksera Dyette, Psy.D. (she/her)
now
00:05:07
Ksera Dyette, Psy.D. (she/her)
ah We're just outlining that we are critical thinkers about what happens in the world around us. So with that said, it's kind of apropos that we're talking about money um because it's very much affected by what's happening right now in the system, but what has always been going on in the system.
00:05:29
Ksera Dyette, Psy.D. (she/her)
And we specifically wanted to focus on not only just the things that people don't understand about how many works with the business of therapy, but also um how taboo it is and some to some degree to talk about what we're going to talk about today. Because people often focus on and we've said this in other episodes, their own frustrations with what therapists are doing.
00:05:59
Ksera Dyette, Psy.D. (she/her)
Versus zooming out to sort of see the system that created the issue. um And that it is not an issue for people to charge what they need to to in order to make a living and not just survive, but thrive, right?
00:06:16
Ksera Dyette, Psy.D. (she/her)
But isn't it completely messed up that we also live in a world where that means that people can't access the care that they need, right? Like both of those things are true at the same time. But because people feel like they can't control what's going on with the system, therapists often end up being the ones who are blamed for trying to live.
00:06:39
Blanca Torres, LMFT
right
00:06:39
Ksera Dyette, Psy.D. (she/her)
There's no other way.
00:06:40
Blanca Torres, LMFT
Right. And everyone's hurting, um'm but we have one common enemy, and that is capitalism.
00:06:48
Ksera Dyette, Psy.D. (she/her)
ah hu Yes, absolutely.
00:06:50
Blanca Torres, LMFT
Well, I more specifics about that, but we'll get to it.
00:06:53
Ksera Dyette, Psy.D. (she/her)
Yeah, yeah. um So, Blanca thought maybe it would be good for us to start this conversation with, like, what you were thinking of when you were building your practice and maybe even before that kind of your um relationship to the business of money when it came to being a therapist, um both maybe working for other people, but then also crafting your practice. And I can also talk about that from my perspective as well.
00:07:27
Blanca Torres, LMFT
When I first started my private practice, immediately out of grad school, so it would have been January 2022, officially February, it was cash only, no insurance, and...
00:07:42
Blanca Torres, LMFT
I knew I wanted to have a sliding scale so i obviously turned to Ksera She supported me in creating a sliding scale based on economic justice which um I believe the method you use.
00:07:54
Blanca Torres, LMFT
Can you remind me the name and the proper citation for that?
00:07:57
Ksera Dyette, Psy.D. (she/her)
Yeah, um Cunning Folk, and I believe it was 2013 or can also that and put it in the show not
00:07:57
Blanca Torres, LMFT
I apologize.
00:08:07
Blanca Torres, LMFT
Yeah, and it's basically where there's three buckets where people choose their fee based on their economic reality. And that really worked really well for me for a long time.
00:08:18
Blanca Torres, LMFT
um i do remember specifically a moment telling my own therapist, was like, oh, I'm going to charge 60 because that's what you were charging when you were an intern. And I started to see you a state intern.
00:08:30
Blanca Torres, LMFT
And as a reminder, a state intern in the state of Nevada In other states, it's called an associate or a pre-licensed professional. Basically, I've graduated. i have an interim license and i'm working under the supervision of a licensed marriage and family therapist.
00:08:45
Blanca Torres, LMFT
um And I remember she was like, Blanca, that was four years ago. Like things cost more now. So just from the beginning, an immediate thing I saw within myself was just
00:09:01
Blanca Torres, LMFT
I have to make myself affordable for everyone and I have to make it not a burden on anyone to access therapy with me. And this is what that might look like.
00:09:14
Blanca Torres, LMFT
So immediately that was where I was at when I started my practice. What about you?
00:09:21
Ksera Dyette, Psy.D. (she/her)
when I started my practice, it was just...
00:09:26
Ksera Dyette, Psy.D. (she/her)
I don't even know if desperation was the right word. But certainly I was in a survival state because I both knew that I didn't want to work full time for anybody ever again. But I didn't know what I was doing.
00:09:42
Ksera Dyette, Psy.D. (she/her)
I didn't know what I was doing. And I've said this before. So many mentors were like, you should start your own practice. But nobody ever said, we're going to show you how to do it and how to think about it. that's why, even though in moments of doubt, when I'm sitting with my coaching clients, I'm like, no, no, I know this is exactly what I need to be doing, right?
00:10:01
Ksera Dyette, Psy.D. (she/her)
Because nobody tells you how to think about things from a to Z and how to make it sustainable.
00:10:08
Blanca Torres, LMFT
correct
00:10:08
Ksera Dyette, Psy.D. (she/her)
So I'd say like my first three years, i was blundering around when it came to money. And I didn't, I was like, okay, I'm going accept these two insurances because that's what most people use in the state.
00:10:26
Ksera Dyette, Psy.D. (she/her)
i didn't do a whole lot of thinking about reimbursement. um Yeah, it was just like, get clients, make money.
00:10:37
Ksera Dyette, Psy.D. (she/her)
(laughing)
00:10:38
Blanca Torres, LMFT
Yes, exactly. Get clients. that's I feel very similarly about that.
00:10:41
Ksera Dyette, Psy.D. (she/her)
Yeah.
00:10:43
Blanca Torres, LMFT
Yeah.
Sliding Scales and Early Practice Struggles
00:10:44
Ksera Dyette, Psy.D. (she/her)
Yeah. And so i had, I mean, the sliding scale was a very early addition because I wanted to do that in a justice informed way. But even then I was in my infancy, so to speak, in terms of how I was thinking about these issues and liberation. Like I didn't know a whole lot about it.
00:11:04
Ksera Dyette, Psy.D. (she/her)
um I learned over time how to talk more about hardship versus sacrifice when talking about the sliding scale with people in a way that honored me as well.
00:11:18
Ksera Dyette, Psy.D. (she/her)
um i think my lowest rate at first didn't really reflect what I needed in order to make a living and not be in a position of hardship myself.
00:11:30
Ksera Dyette, Psy.D. (she/her)
ah So I adjusted it over time, but definitely I think like my initial money decisions were just survival. um
00:11:40
Blanca Torres, LMFT
Yeah.
00:11:41
Ksera Dyette, Psy.D. (she/her)
And I used to have this friend in grad school, friend acquaintance, I guess, who would always say to me, you have to spend money to make money. And i was like, what does that even mean?
00:11:54
Ksera Dyette, Psy.D. (she/her)
It sounded so ridiculous to me, but I still remember it because um there were things that I was spending time doing that were also taking away from my ability to actually be able to serve clients and make money um that I ended up having to pay other people to do, like hiring an accountant who was also my CFO.
00:12:15
Blanca Torres, LMFT
Right.
00:12:17
Ksera Dyette, Psy.D. (she/her)
um Like, why am I sitting on the floor doing my own accounting for my business? Just because i can doesn't mean I should. So those were a lot of like how I related to money, like in the first few years.
00:12:32
Blanca Torres, LMFT
Yeah, I really relate to that. The idea of like survival and just get clients. I think my lowest session fee was $40. Yeah. forty dollars um I've made allowances for even less if a client is going through a hardship and then, you know, and I know there were, we have an agreement for what the ending that might look like.
00:12:53
Blanca Torres, LMFT
um But I'm curious, what was your lowest at the beginning?
00:12:57
Ksera Dyette, Psy.D. (she/her)
Yeah, um I think my lowest at the beginning was 80, which for me, like, it is low.
00:13:04
Ksera Dyette, Psy.D. (she/her)
and it was certainly slightly, yeah it was slightly lower than my um my lowest network reimbursement.
00:13:06
Blanca Torres, LMFT
That is low.
00:13:13
Ksera Dyette, Psy.D. (she/her)
So i was actually getting paid more from insurance at that point for my lowest reimbursement. which for us um is technically a 90834, which is 45 minute session.
00:13:26
Ksera Dyette, Psy.D. (she/her)
ah There's one that's lower than that, but typically we I'm not doing those sessions. um But yeah, that was my lowest. Even my cancellation sort of policy fees didn't reflect something that was sustainable for me either.
00:13:42
Ksera Dyette, Psy.D. (she/her)
um Again, I was blundering through working in what felt like care in my policies like for example with um parents especially when i was seeing a lot more children i had every six months one free cancellation because kids get sick and at the time my practice was in person and this was before covid um and i used to say like don't bring your kids if they have a fever just because you're worried about the late fee because
00:14:18
Ksera Dyette, Psy.D. (she/her)
if I get sick, then your kid has no therapist. Um, so I would have those freebies worked in.
00:14:23
Blanca Torres, LMFT
Right.
00:14:25
Ksera Dyette, Psy.D. (she/her)
So usually somebody late cancel, I'd be like, Hey, you have your free cancellation. Do you want to use it or not? And they would choose to use it. And then it resets. Um, I still have that.
00:14:36
Ksera Dyette, Psy.D. (she/her)
Um, and of course I'm chronically ill. So I understand chronic health issues, um, like migraine and things like that. And I feel like I've gotten to the point where I can tell where someone isn't like abusing my flexibility with that.
00:14:53
Ksera Dyette, Psy.D. (she/her)
Like, um so similarly to you, I've made concessions in different circumstances or um one of my money related traumas happened with my first therapist because he wouldn't give me just like a temporary low fee agreement while we were working out an insurance issue.
00:15:14
Ksera Dyette, Psy.D. (she/her)
Um, and he was like, I'm comfortable with you. Like just having me like owing me the money until you're able to pay it. And I was like, well, I'm not comfortable with that because basically I'm racking up a debt while I'm waiting to find out if the insurance company is going to grant you a single case agreement.
00:15:27
Blanca Torres, LMFT
Right.
00:15:37
Ksera Dyette, Psy.D. (she/her)
Um, and I'll explain in what that is for people that don't understand, um, to allow you to keep seeing me. So what happened is my job, they changed the insurance that we had, and he was not in network with that new insurance company.
00:15:51
Ksera Dyette, Psy.D. (she/her)
And sometimes for continuity of care, the insurance company will allow the therapist to argue for what's called a single case agreement, where they'll reimburse you at a contracted rate so that you can keep seeing the client so that their care isn't interrupted.
00:16:07
Ksera Dyette, Psy.D. (she/her)
um And I've done one of these for my for my own clients. um and it's actually not that complicated to do
00:16:14
Blanca Torres, LMFT
Oh, good.
00:16:14
Ksera Dyette, Psy.D. (she/her)
And we went through the process and they denied it. They denied it And I had stopped seeing him because I was like, I just can't afford to do this. And he's like, well, I know you'll pay me back eventually. And I'm like, I don't want to be in that position with you.
00:16:31
Blanca Torres, LMFT
Right.
00:16:32
Ksera Dyette, Psy.D. (she/her)
So, and it's in our ethics code that we don't create a debt ah debtor creditor relationship with our clients.
00:16:40
Blanca Torres, LMFT
Right.
00:16:40
Ksera Dyette, Psy.D. (she/her)
So when I um had things like a client losing their job or something like that, like we would create a temporary agreement, but it had to have an end date, at least, you know, for both of us, right? Like, I can't be resentful about the fact that this is costing me more than I can actually...
00:17:01
Ksera Dyette, Psy.D. (she/her)
Like I have to give, but you deserve to know that I'll still keep seeing you until a specified period of time.
00:17:03
Blanca Torres, LMFT
right
00:17:07
Ksera Dyette, Psy.D. (she/her)
I've also hooked up clients with scholarships for therapy that have allowed me to get paid in those kinds of circumstances. um So I veered off a little bit from the, what was your lowest?
00:17:21
Ksera Dyette, Psy.D. (she/her)
I think that was the initial question you asked me, um but those are other things that I have also done similar to you.
00:17:23
Blanca Torres, LMFT
Yeah, it was. Yeah.
00:17:30
Blanca Torres, LMFT
Yeah. And I appreciate that first therapist of yours intentions, but there it's not the context isn't really very well thought out um because, yeah, it's against your ethics code.
00:17:39
Ksera Dyette, Psy.D. (she/her)
No.
00:17:43
Blanca Torres, LMFT
And also, what if you just disappeared or really couldn't afford to back pay 10 sessions?
00:17:51
Ksera Dyette, Psy.D. (she/her)
And I couldn't.
00:17:52
Blanca Torres, LMFT
At how much per session?
00:17:52
Ksera Dyette, Psy.D. (she/her)
Oh gosh, I think it was like, maybe 150 or something, I can't remember, but it was, yeah.
00:17:59
Blanca Torres, LMFT
i and Most Americans don't have a money for and and a $1,000 emergency. how What are the chances you could just drop $1,500?
00:18:06
Ksera Dyette, Psy.D. (she/her)
Yeah.
00:18:10
Blanca Torres, LMFT
Yeah.
00:18:11
Ksera Dyette, Psy.D. (she/her)
Yeah.
00:18:13
Blanca Torres, LMFT
on something. I couldn't. and At least not in our youth.
00:18:15
Ksera Dyette, Psy.D. (she/her)
Yeah.
00:18:17
Ksera Dyette, Psy.D. (she/her)
No, I mean, and I was, that was like, I was in a, group at that time I was in a group practice job With like $34,000, $32,000
00:18:30
Ksera Dyette, Psy.D. (she/her)
salary right and i was like my rent was like nine hundred for a room that i was subletting Right. Like, let alone all of the other expenses. So, yeah, I didn't have it. And he he was like, well, I think that this is important because, you know, you have some some psychological.
Ethics in Financial Agreements
00:18:52
Ksera Dyette, Psy.D. (she/her)
I don't remember exactly how he said it, but essentially he was arguing that because I had stuff having to do with money as part of my own psychological whatever. that that was why he needed to hold on to me paying the fee as it was.
00:19:10
Ksera Dyette, Psy.D. (she/her)
um And I said to him that like, you know, sometimes a cigar Could be something else, but sometimes a cigar is just a cigar.
00:19:23
Ksera Dyette, Psy.D. (she/her)
And the fact of the matter is, is like, maybe there is money stuff for me to process because I've been poor my whole life.
00:19:23
Blanca Torres, LMFT
Right.
00:19:30
Ksera Dyette, Psy.D. (she/her)
All right. And I have a lot of money trauma um and fears around scarcity that are both real, right? Right now in this moment, but also have been true for me in my life.
00:19:42
Ksera Dyette, Psy.D. (she/her)
But it's also true that I just can't pay you.
00:19:44
Blanca Torres, LMFT
Right. ah you're Right.
00:19:46
Ksera Dyette, Psy.D. (she/her)
Right.
00:19:48
Blanca Torres, LMFT
This is not an if she wanted to, she would kind of situation. Like, this is not trauma holding you back.
00:19:52
Ksera Dyette, Psy.D. (she/her)
Right.
00:19:54
Blanca Torres, LMFT
This is literal dollars in your bank account holding you back.
00:19:58
Ksera Dyette, Psy.D. (she/her)
Right. right
00:19:59
Blanca Torres, LMFT
Yeah.
00:19:59
Ksera Dyette, Psy.D. (she/her)
And so.
00:19:59
Blanca Torres, LMFT
Yeah.
00:20:00
Ksera Dyette, Psy.D. (she/her)
That ah like I walked out and it was so hard. Like I felt like, don't know, maybe heartbroken was probably a good way to describe it. ah Because I had been in therapy with this therapist for like two years.
00:20:13
Ksera Dyette, Psy.D. (she/her)
um But the way he handled the money thing was just awful.
00:20:19
Ksera Dyette, Psy.D. (she/her)
And um I didn't want to repeat that with people in my business. I knew that as much. And so does that mean I've had people who have had, I have had people who've had to stop services as a result of financial concerns.
00:20:37
Blanca Torres, LMFT
absolutely
00:20:37
Ksera Dyette, Psy.D. (she/her)
um But I really take a lot of care around how we handle that. And i typically try to exhaust, offer to exhaust my options before we get to that point, like pursuing the single case agreement, for example.
00:20:53
Ksera Dyette, Psy.D. (she/her)
I was, that all of that paperwork has to be done by me.
00:20:57
Blanca Torres, LMFT
Which you don't get paid for.
00:20:57
Ksera Dyette, Psy.D. (she/her)
But, which you don't get paid for.
00:21:00
Ksera Dyette, Psy.D. (she/her)
But anyway, um yeah. and so that all of those experiences color,
00:21:09
Ksera Dyette, Psy.D. (she/her)
and shape how I've approached the money issue in my business.
00:21:14
Ksera Dyette, Psy.D. (she/her)
So I'm curious about just like, but we've talked about insurance, but we haven't really talked about the decisions we've made around taking it versus not.
00:21:25
Ksera Dyette, Psy.D. (she/her)
Um, and like, where are you at now with respect to that?
00:21:30
Blanca Torres, LMFT
I currently take insurance. um I only take a couple through my private practice, um but I take many of the major ones through an agency I contract with.
00:21:43
Blanca Torres, LMFT
um But I started taking insurance The reason I started taking insurance is I saw i was working part time still at my office job and part time at my private practice, which was cash pay only. And it was doing well that it was it was time to jump ship.
00:22:01
Blanca Torres, LMFT
But um like Ksera I don't have wealthy parents. I don't have a spouse To fall back on, ah the entirety of my bills are exclusively entirely on me.
00:22:19
Blanca Torres, LMFT
And so I couldn't, I simply could not take the risk of jumping from... a part-time job in a part-time private practice to a full-time private practice and just hoping the clients come in. So I had to make the choice to join an agency and and take some insurance and fill my caseload that way.
00:22:40
Blanca Torres, LMFT
um And that that is how ultimately I was able to leave my other ah other job and just be a full-time therapist. So really the decision for me was like was a financial one um i would !00% prefer to see only cash pay but population i desire to work with might have enough to cover their copay and cover their insurance premium but not necessarily enough to cover my cash pay rate a weekly
00:23:13
Blanca Torres, LMFT
um At that time. And I'm not, I'm certainly not putting myself as in myself in any corners or anything like that. i am open to the journey and what it takes me, but that was what led me to taking insurance.
00:23:26
Blanca Torres, LMFT
And there's a ton, a ton of headaches, a ton of headaches. But I just simply needed to pay my mortgage and that was the way I could do it.
Insurance Challenges in Therapy Practices
00:23:39
Ksera Dyette, Psy.D. (she/her)
And have,
00:23:39
Blanca Torres, LMFT
What about you?
00:23:41
Ksera Dyette, Psy.D. (she/her)
oh how have how you're thinking about it changed at all since then?
00:23:50
Ksera Dyette, Psy.D. (she/her)
Has.
00:23:51
Blanca Torres, LMFT
Yeah.
00:23:54
Blanca Torres, LMFT
It has. i mean,
00:23:59
Blanca Torres, LMFT
the way that I see it now for me personally, and please no one ever feel like the what works for me has to work for you. For me this time and place in my practice and in my life, it feels like a necessary evil.
00:24:18
Blanca Torres, LMFT
Because there are a lot of people out there simply cannot afford therapy. They simply cannot ah afford a cash pay rate, but they have their insurances um that cant that will pay.
00:24:29
Blanca Torres, LMFT
But some of the things that insurance companies have put me through, there's one actively trying to remove a client. from getting therapy benefits because they believe they're accessing it too much to the point where they forced a client to participate in a program that she quote unquote, didn't need to consent to and forced me to discuss with a case manager at an insurance company, how to get her off of therapy.
00:25:00
Blanca Torres, LMFT
And I can't say more because of confidentiality, but this is, it's it's just atrocious. It's not okay. To the point where I had to tell this insurance company, like, you are talking about this person.
00:25:14
Blanca Torres, LMFT
And like, they're medical case. that you can track is her, is there cholesterol going up or going down? Like this is a human being with layers and layers of complex trauma.
00:25:28
Blanca Torres, LMFT
There's going to be weeks where things are great and boundaries are set and, And the person is thriving. And then there's going to be weeks when they're exhausted from all the trauma and everything else going on in their life where it's harder to set boundaries, where it's harder to maintain progress, blah, blah, blah.
00:25:44
Blanca Torres, LMFT
ah To the point where I'm pretty sure I made the person cry because there was like a little (noise) in their voice when I stopped my little monologue. um But I find that horrendous. i Just atrocious behavior from an insurance company.
00:25:59
Blanca Torres, LMFT
Ironically, I have the same insurance company through the marketplace and they have been pushing for an in-home physical exam.
00:26:08
Ksera Dyette, Psy.D. (she/her)
Oh, what the
00:26:09
Blanca Torres, LMFT
Swear to God, Ksera they call me every other day. We want to tell you about this great program. We'll come to your house and do a physical exam. And I'm like, no, I have a primary care physician.
00:26:20
Ksera Dyette, Psy.D. (she/her)
hell?
00:26:22
Blanca Torres, LMFT
I am access ah accessing my medical care. You are an insurance company, not a medical provider. You do not get to come in and do a medical assessment on me. This is why I see doctors.
00:26:33
Ksera Dyette, Psy.D. (she/her)
Ewe
00:26:33
Blanca Torres, LMFT
You are an insurance company. Stay in your lane. And they're like, no, no, no. I'm like, no, you need to be quiet and listen to me. What this is doing is you're trying to get into my home to make decisions about my hair my care to ultimately raise my premiums.
00:26:46
Blanca Torres, LMFT
You have no business getting this involved in my healthcare other than paying for it, which is i pay what I pay you about. Anyway, I'm going on a tangent. But what I'm saying is insurance companies are fucking horrific.
00:26:59
Blanca Torres, LMFT
And
00:27:04
Blanca Torres, LMFT
Some people need to use your insurance to access care.
00:27:07
Ksera Dyette, Psy.D. (she/her)
Mm-hmm.
00:27:07
Blanca Torres, LMFT
and And I also just want to really, I've noticed like within the therapy field, there's tension. There's people who judge who people who don't take insurance. And there's people who judge people who do take insurance.
00:27:20
Blanca Torres, LMFT
And I really don't think that's fair because there's enough out there for all of us. And we all get to decide what and how
00:27:30
Blanca Torres, LMFT
What makes sense, excuse me, what makes sense to run our practices? For me right now, this makes sense to run my practice. Will that be the case in two years or five or fuck six months?
00:27:42
Blanca Torres, LMFT
I don't know. and don't know. And I'm willing to like make changes if I need to. But as of right now, like that, that's where I'm at. um They are horrendous.
00:27:53
Blanca Torres, LMFT
And
00:27:53
Ksera Dyette, Psy.D. (she/her)
Yes. Yes. And, you know, but the judgment thing is so interesting to me because it's really not considered, like, consistent with liberation, right?
00:27:56
Blanca Torres, LMFT
I got to do what I got to do.
00:28:06
Blanca Torres, LMFT
Right.
00:28:07
Ksera Dyette, Psy.D. (she/her)
Like, if we're really thinking about it, why are you doing that? Right? Like, why are you doing that? It almost, like, feels very similar to me as the, like,
00:28:21
Ksera Dyette, Psy.D. (she/her)
divestment from licensure conversation, right?
00:28:26
Blanca Torres, LMFT
Mm hmm. Mm hmm.
00:28:27
Ksera Dyette, Psy.D. (she/her)
Where there's like a judgment sometimes from the folks who have divested to the people who have not and vice versa, right?
00:28:40
Ksera Dyette, Psy.D. (she/her)
Where they're the people who have not, who are like, well, they're not really, if they're not licensed, then they're not. you know, all of the stuff that I find to just be like, just distracting from our ability to unify around the fights that we actually need to be able to.
00:29:02
Ksera Dyette, Psy.D. (she/her)
ah so that's just like a parenthetical comment to the judgment piece, um, that I think is important here. Um, but to go back, um,
00:29:15
Ksera Dyette, Psy.D. (she/her)
I didn't have any deep thoughts about taking it other than like, these are the ones I know people are going to be looking for me who used to see me at this other practice.
00:29:26
Ksera Dyette, Psy.D. (she/her)
um I wasn't actively recruiting them. They found me and I just knew they were going to be using insurance.
00:29:33
Ksera Dyette, Psy.D. (she/her)
That was literally it.
00:29:37
Ksera Dyette, Psy.D. (she/her)
However, the more I dealt with insurance, the more personal my feelings became about it. Because I just like, so we get these, um so here's the tea, y'all, in case you don't know.
00:29:51
Ksera Dyette, Psy.D. (she/her)
We get these reimbursement schedules, these fee schedules, that tell us how much the insurance company is going to pay us for different codes, different billing codes of services.
00:30:04
Blanca Torres, LMFT
Mm-hmm.
00:30:06
Ksera Dyette, Psy.D. (she/her)
And we are legally required to not disclose what those rates are. So when I have this conversation, i always say, I'm not going to tell you any real numbers, but I am going to give you a very real picture with some fake numbers.
00:30:26
Ksera Dyette, Psy.D. (she/her)
So if hypothetically speaking, my out-of-pocket rate is $250 hour, may be $250.
00:30:37
Ksera Dyette, Psy.D. (she/her)
see eighty dollars of the two hundred and fifty dollars for the session, my 45-minute session, or maybe $115 for my 60-minute session.
00:30:56
Ksera Dyette, Psy.D. (she/her)
Now, if these numbers approximate real reimbursement rates, that's totally unintentional because I'm just picking arbitrary numbers. FYI, insurance companies, if you're listening in.
00:31:08
Blanca Torres, LMFT
Right.
00:31:11
Ksera Dyette, Psy.D. (she/her)
But that's a pretty good estimate of a gap that we would see for our services.
00:31:17
Blanca Torres, LMFT
Right. right
00:31:20
Ksera Dyette, Psy.D. (she/her)
And we've talked about this before. We understand that these numbers that we're working with are still much higher than most minimum wage
00:31:31
Ksera Dyette, Psy.D. (she/her)
Right. And we already feel that minimum wage is criminal as a system. OK, so I just want to put that there as we have this conversation, because we've acknowledged that in another episode as well.
00:31:39
Blanca Torres, LMFT
right
00:31:44
Ksera Dyette, Psy.D. (she/her)
But we have so many other expenses to take into account on the money that we make. We have taxes that we have to pay 30 percent okay on the money that we make.
00:32:00
Ksera Dyette, Psy.D. (she/her)
We have the overhead for our businesses, which is less if you don't have an office, but you still have to pay. If you're doing electronic medical record of some kind, you're usually paying for that software.
00:32:11
Blanca Torres, LMFT
which are required Which are required by most ethics boards now. I do believe most ethics boards are moving to you have to have electronic medical records.
00:32:16
Ksera Dyette, Psy.D. (she/her)
Yes.
00:32:22
Blanca Torres, LMFT
And that's not a PDF on your computer. That is an electronic health record system like simple practice, therapy notes, etc.
00:32:26
Ksera Dyette, Psy.D. (she/her)
Mm-hmm.
00:32:32
Blanca Torres, LMFT
That can cost upwards of $100 a month.
00:32:33
Ksera Dyette, Psy.D. (she/her)
Yep.
00:32:36
Ksera Dyette, Psy.D. (she/her)
Mm-hmm.
00:32:36
Blanca Torres, LMFT
For one that you need that has everything you need.
00:32:36
Ksera Dyette, Psy.D. (she/her)
Mm-hmm.
00:32:39
Ksera Dyette, Psy.D. (she/her)
Yes.
00:32:39
Ksera Dyette, Psy.D. (she/her)
And many of those um platforms are innovating. They're continuing to add more features as therapists request them and ask for them. Obviously, those things cost money. the people who are running those businesses have to get paid as well.
00:32:54
Ksera Dyette, Psy.D. (she/her)
And so we've seen um how much our software is costing us go up as well. In addition to that, you
00:33:00
Blanca Torres, LMFT
And then can I add on software for accounting services?
00:33:02
Ksera Dyette, Psy.D. (she/her)
Yeah. Go ahead.
00:33:08
Ksera Dyette, Psy.D. (she/her)
Yes.
00:33:08
Blanca Torres, LMFT
QuickBooks, etc. Yep.
00:33:09
Ksera Dyette, Psy.D. (she/her)
QuickBooks. Yep. Or what you pay your accountant in my case, who's also on my CFO.
00:33:14
Blanca Torres, LMFT
yeah
00:33:17
Ksera Dyette, Psy.D. (she/her)
um We also have our um CEUs. So continuing education that we have to maintain for our licensure.
00:33:29
Ksera Dyette, Psy.D. (she/her)
those costs money or any conferences that we attend may cost money or travel to conferences that we attend to just continue to get more education.
00:33:37
Blanca Torres, LMFT
Which is thousands, yeah, which can be thousands of dollars a year, even if you're not traveling. Even if you're not traveling, even if you're doing a training that that's fully online, it's still upwards of $15,000 to $2,000 for only a fraction of the community or the continuing education hours you need.
00:33:45
Ksera Dyette, Psy.D. (she/her)
Mm-hmm.
00:34:00
Ksera Dyette, Psy.D. (she/her)
Exactly. And it may not even cover all the topics that you need because we have certain areas that we have to get credits for. um And I forgot somewhere in there because I had a list in my mind of the different expenses, but you can sort of get a picture now of what actually happens with that money.
00:34:22
Ksera Dyette, Psy.D. (she/her)
And we still have to pay ourselves. Right.
00:34:27
Ksera Dyette, Psy.D. (she/her)
so that we can also pay our bills and put food on the table.
00:34:32
Blanca Torres, LMFT
Mm-hmm.
00:34:32
Ksera Dyette, Psy.D. (she/her)
And um unlike Blanca,
00:34:37
Ksera Dyette, Psy.D. (she/her)
um I'm currently... in partnered situation where I am receiving some support from my partner. However, I always operate after some relationship trauma. You'll get a little bit of personal information about me.
00:34:53
Ksera Dyette, Psy.D. (she/her)
have a long-term relationship where I was in, where I was taking care of all of the finances. um that that really left me in like just financial shambles um because I was the primary breadwinner. And so I always operate as if I am, i have to 100% be able to take care of myself.
00:35:14
Ksera Dyette, Psy.D. (she/her)
I don't care if I'm with anybody else or not. I need to know that the money that I'm bringing in can take care of me without another person. but um especially because I have health issues and all of these other things. So um I operate my business as if I am single.
00:35:32
Ksera Dyette, Psy.D. (she/her)
That is the way I operate my business.
00:35:35
Ksera Dyette, Psy.D. (she/her)
um And I think it's just really important to consider also like the different places where we are as well. um Obviously, there's different financial considerations, but where I am, Boston is really freaking expensive.
00:35:51
Ksera Dyette, Psy.D. (she/her)
ah Like the possibility of owning a home is just like non-existent. Um, so I just want you to think about the listener. If you're not a therapist,
00:36:06
Ksera Dyette, Psy.D. (she/her)
like I'm really painting this picture for those of you who don't understand sort of the economic realities of like what actually goes into a therapist considering how they price their services.
00:36:20
Ksera Dyette, Psy.D. (she/her)
Because this just isn't about wanting to be balling out of control.
00:36:20
Blanca Torres, LMFT
Right.
00:36:25
Ksera Dyette, Psy.D. (she/her)
right It's so many things. And and to some degree, insurance can be a necessary evil. But I also think, like again, if we can be in community about different ways that we're thinking about these systems, it doesn't have to be necessarily. And I say that because like there's so many other places where, again, they've put in these scholarships in place.
00:36:51
Ksera Dyette, Psy.D. (she/her)
um Some folks use a Robin Hood model, as we sort of call it, which I do as well. um higher cost services, supplement lower cost services, or allow me to offer pro bono spots, which I have done.
Balancing Finances with Client Care
00:37:08
Ksera Dyette, Psy.D. (she/her)
um i have offered like pro bono spot for a client before. I've offered lower than my lowest fee spots for folks and that's supplemented by other aspects of my business ah that are not bound to insurance.
00:37:24
Ksera Dyette, Psy.D. (she/her)
So um I think it's that's a way that i try to counter that. and um But I also do think that it's important that we don't get into the trap of people feeling like they're just being greedy if they're not doing those things, right?
00:37:42
Blanca Torres, LMFT
Right.
00:37:45
Ksera Dyette, Psy.D. (she/her)
Because everybody, everybody deserves to decide what they need and what that looks like.
00:37:53
Blanca Torres, LMFT
and
00:37:54
Ksera Dyette, Psy.D. (she/her)
Mm-hmm.
00:37:54
Blanca Torres, LMFT
And what their business model looks like. Right. um I've tried doing assessments. I did it for a while. It was nice. I found them to be almost more traumatic.
00:38:08
Blanca Torres, LMFT
the type of um evaluations i do as I was doing, immigration evaluations. And if I got one now, I would consider doing it, but they were so deeply traumatic, you know, that that ended up being harder for me.
00:38:18
Ksera Dyette, Psy.D. (she/her)
Mm-hmm. Mm-hmm.
00:38:21
Blanca Torres, LMFT
So for me, what works right now is seeing clients. That's what works right now. Um, and as I'm not interested in shaking it up, um,
00:38:33
Blanca Torres, LMFT
simply because of the context of our times. Like I'm i'm i'm trying to figure out figure out a way to survive autocracy. um So it's not the time to be like, let me try this with my business today. You know, for me personally, I also want to add a a little more context to what Ksera was talking about earlier with why things cost the way they cost. Like $80 sounds like a lot of money per hour. Yeah. It sounds like a ton of money per hour.
00:39:00
Blanca Torres, LMFT
But most therapists aren't working 35, 40 hours a week. and Excuse me. They're not seeing clients 30 to 40 hours a week, right?
00:39:07
Ksera Dyette, Psy.D. (she/her)
Right. Right.
00:39:09
Blanca Torres, LMFT
We might be working that many hours but because we're doing notes, we're doing assessments, we're following up with insurance. But the actual money per hour that we make, we only see it when we're actively seeing those clients.
00:39:22
Blanca Torres, LMFT
And so as much as it sounds like a ton of money, it's really not.
00:39:22
Ksera Dyette, Psy.D. (she/her)
right
00:39:28
Blanca Torres, LMFT
It's really not. And it also doesn't account for licensing fees. My license is up for renewal at the end of this year. It's $450. And that's on top of the 40 hours of continuing education credits that I had to get over the last two years.
00:39:45
Blanca Torres, LMFT
It doesn't account for student loans that we have to be paying back, right?
00:39:48
Ksera Dyette, Psy.D. (she/her)
Oh yeah.
00:39:51
Blanca Torres, LMFT
There's, if up into before your license, there's supervision costs. I was spending almost $600 a month on supervision costs before I was taking insurance.
00:40:02
Blanca Torres, LMFT
So when I was seeing clients at $40 an hour, 60, 80, right out of that, I had to somehow get almost, almost, not quite, almost $600 a month to pay for supervision.
00:40:14
Blanca Torres, LMFT
Then if you are taking insurance independently to get on insurance panels, that's over a thousand dollars depending on how many panels you want to be on, right? Then unless you're doing the billing yourself, which is an entire specialty that you can and should get trained on if you're going to be a biller, if you're hiring a biller, that's an added cost. So either you're teaching yourself billing and you're spending countless amount of time Submitting claims, following up on claims, fighting about claims.
00:40:44
Blanca Torres, LMFT
If you're not doing that, you're paying someone to do that for you. Right? And then there's the things Ksera and I don't have to worry about right now, like rent. my The last place I rented was percentage-based.
00:40:57
Blanca Torres, LMFT
The more money I made, the more money she made. Right? So it's not like i was seeing all these clients and making all this money. Nope. It was go it just my rent cost increased.
00:41:08
Blanca Torres, LMFT
It also doesn't account.
00:41:08
Ksera Dyette, Psy.D. (she/her)
Which felt so illegal.
00:41:10
Blanca Torres, LMFT
I know. I know. But it's so common. It was such a cute office too. I miss it. um Then there's like other things that you don't think about. Like internet. We have to have solid internet. I cannot risk my internet going in and out.
00:41:24
Blanca Torres, LMFT
I cannot risk my internet getting bogged down if my roommate is playing a video game or if someone else in my household is watching Netflix. Right. Then there's health insurance costs. My own health insurance premium is $550 a month.
00:41:40
Blanca Torres, LMFT
No employer pays that for me. I pay that for me. So just a little bit of added context. um I hope we're not freaking out anyone who wants to do a private practice.
00:41:51
Blanca Torres, LMFT
These are the realities of running your own business. um
00:41:55
Blanca Torres, LMFT
It's the cost of admission of running your own business. I'm sure I could get a job working full time for a salary somewhere where I couldn't choose my clients. I couldn't choose my hours. But hey, maybe some of this other stuff would be taken care of.
00:42:08
Blanca Torres, LMFT
And maybe that's worth it. I don't know. Not where I'm at right now. But.
00:42:12
Ksera Dyette, Psy.D. (she/her)
I'm glad you mentioned in the supervision thing, because that's... Oh, man. They... Like...
00:42:21
Ksera Dyette, Psy.D. (she/her)
So again, ah after we graduate, again, for those of you who are not familiar with the context or learning about, you know, you're here because you want to learn, um we have to be supervised for a certain amount of hours in order to get our licensure.
00:42:38
Ksera Dyette, Psy.D. (she/her)
And so it's very common for people to join group practices as a way of doing that, because supervision is kind of offered as a perk, so to speak, um as in sort of a trade for you accepting a lower salary um and also your reimbursements are lower as an unlicensed provider who has to be supervised there. All your notes have to be signed off on by your supervisor.
00:43:11
Ksera Dyette, Psy.D. (she/her)
um And it's, and it's not an unusual place for practices to trap people. new clinicians and I use trap intentionally um because a lot of people don't want to negotiate all of the things that we're talking about and so therefore it's much easier to just stay with a group practice that is actively exploiting you you may not be aware of it but most of them are
00:43:38
Ksera Dyette, Psy.D. (she/her)
um I mentioned this on a previous episode, a clinician who i i think i will take credit for pushing her to reconsider this job. She was making $50 an hour. And just like, what in the world? And, you know, she's working until like 10 o'clock at night, seeing folks after working like a full-time job all day.
00:44:02
Ksera Dyette, Psy.D. (she/her)
And, and Like a lot of these practices are just like, okay, you don't want to deal with it. We will, but don't worry about it. And you don't know what goes on in the background, like the fact that they might be able to renegotiate their rates because groups um can get renegotiate higher reimbursements than individuals can.
00:44:25
Ksera Dyette, Psy.D. (she/her)
Some insurance companies put a cap on that, so they'll say you have to have at least five clinicians to be considered for a group reimbursement um renegotiation.
00:44:37
Ksera Dyette, Psy.D. (she/her)
So there are all these constrictions and stipulations, and practices are just poised to be like, oh, you just got out of school, we're going to take you, and we're going to hope that you never leave.
00:44:48
Ksera Dyette, Psy.D. (she/her)
But then people really burn out um in those kinds of settings. And two of my coaching clients are exactly in that position. They are wanting out of their agencies because they're burnt out and and totally exploited.
00:45:05
Ksera Dyette, Psy.D. (she/her)
um And they're barely making ends meet, right?
00:45:10
Blanca Torres, LMFT
Mm-hmm.
00:45:11
Ksera Dyette, Psy.D. (she/her)
And so if you had to ask us, maybe later, we'll hold this question for later. Like, so why do we do it? so we We both have answers and to that question.
00:45:22
Ksera Dyette, Psy.D. (she/her)
ah But I wanted to talk Blanca a little bit about, you kind of touched on this, like the ah tension between the need to make a living and what feels accessible and sustainable,
00:45:44
Ksera Dyette, Psy.D. (she/her)
um not just for your clients, but for you. Like, how do you negotiate that dilemma in your mind?
00:45:59
Blanca Torres, LMFT
well
00:46:01
Blanca Torres, LMFT
You couldn't have gone with something easier? um How do i negotiate that dilemma?
00:46:04
Ksera Dyette, Psy.D. (she/her)
Never. Never.
00:46:11
Blanca Torres, LMFT
I mean, I think, well, one, I think it just takes time. i didn't get into this line of work to be a millionaire. i also didn't get into this line of work to starve or not have what I need.
00:46:30
Blanca Torres, LMFT
There's also a reality that in order to do this job well, I have to take care of myself. And that looks like not working 40 hours a week.
00:46:41
Blanca Torres, LMFT
I mean, client hours, right? Like that. oh my God. Um,
00:46:49
Blanca Torres, LMFT
I think where I've landed is that, oh God, i don't know. It's just so it's so nuanced. So please, please, please forgive me for whatever nuance might be missing from what I'm about to say.
00:47:07
Blanca Torres, LMFT
We're all existing under capitalism and we all have to negotiate what we want versus what we need.
00:47:19
Blanca Torres, LMFT
And what we want to prioritize. Right. And folks who maybe want to see me who don't have insurance, who pay my cash pay rate, they have.
00:47:34
Blanca Torres, LMFT
This is a necessity for them and they work it into their budget. They just do, you know.
00:47:45
Blanca Torres, LMFT
but And whether that's a $10 copay or $120 cash rate or more, or whatever, people figure it out, right? Like my own therapist is cash pay only.
00:47:59
Blanca Torres, LMFT
Her fee is up there, $150. it's high. yeah But I've negotiated way in my budget to pay it and she deserves it. Right. She's earned that money.
00:48:09
Blanca Torres, LMFT
um So I guess imperfectly that that's how I've negotiated it is that if people have the ability to prioritize it, they will.
00:48:23
Blanca Torres, LMFT
And if they can't, well, that's why I take Medicaid and that's why I take the plans that are most commonly taken in where I live by working class people, you know?
00:48:36
Blanca Torres, LMFT
So that's, does that answer your question?
00:48:39
Ksera Dyette, Psy.D. (she/her)
I mean, it's your answer.
00:48:43
Ksera Dyette, Psy.D. (she/her)
It's your answer. I think for me, this has looked like a lot of different things over the years um because sustainable negotiation also means what I can physically do.
00:49:01
Ksera Dyette, Psy.D. (she/her)
um If I'm sitting there with you, feeling like, oh my God, i don't want to be here right now because i feel like I'm worried about making ends meet.
00:49:14
Ksera Dyette, Psy.D. (she/her)
That's not good for you, right
00:49:17
Blanca Torres, LMFT
Mm-hmm.
00:49:18
Ksera Dyette, Psy.D. (she/her)
um I have to feel good. I have to feel good. um So this is this has become kind of an open dialogue conversation with clients when many issues come up.
00:49:32
Ksera Dyette, Psy.D. (she/her)
It's also a background conversation that I'm constantly having with myself. And I also talk with clinicians about being mindful of their spots and how they fill them. Because that might mean, like, for example, maybe you know you can offer one pro bono spot and that's all you can offer.
00:49:53
Ksera Dyette, Psy.D. (she/her)
And that's okay.
00:49:55
Blanca Torres, LMFT
Which I do, for the record.
00:49:55
Ksera Dyette, Psy.D. (she/her)
Maybe, yeah.
00:49:59
Ksera Dyette, Psy.D. (she/her)
Maybe you can offer one fee one low fee spot that's lower than your typical rate when somebody is in an emerging situation.
00:50:08
Blanca Torres, LMFT
Mm-hmm.
00:50:09
Ksera Dyette, Psy.D. (she/her)
right Maybe you can offer two. It just all depends. You do have to know what's going on with your money, though, in order to be able to make these decisions. And so financial literacy...
00:50:22
Ksera Dyette, Psy.D. (she/her)
And increasing your financial literacy is really important if you're going to do this.
00:50:26
Blanca Torres, LMFT
Mm-hmm.
00:50:28
Ksera Dyette, Psy.D. (she/her)
And I say that because, um yeah, I hired an accountant, but my accountant also had made, and they're not my accountant anymore, a huge mistake with my taxes um that I didn't catch.
00:50:46
Ksera Dyette, Psy.D. (she/her)
um And it cost me a lot of money. and (clears throat) Then I was watching all my paperwork like a hawk after that.
00:50:57
Ksera Dyette, Psy.D. (she/her)
um And I did catch errors the following year. um But like you can't not watch your money. You just can't.
00:51:09
Ksera Dyette, Psy.D. (she/her)
ah So you may hand it over to somebody to handle like the fi like filling out the paperwork and all of that. But you better know what you're looking at and ask as
00:51:19
Ksera Dyette, Psy.D. (she/her)
many questions as you need to ask and know why numbers are where they are, right? Like, and then all your W-2s and all of these different forms, the 1095s, so on, all of those things are accounted for, right?
00:51:30
Ksera Dyette, Psy.D. (she/her)
um But I say that because, like, in order to make some of these decisions, you have to know what you're actually making, right? what you're paying for your taxes, all of these different things.
00:51:43
Ksera Dyette, Psy.D. (she/her)
um Because that does allow me to negotiate what these, what I can offer that is still within reach for the people that I want to serve, but doesn't mean that I completely have to sacrifice everything in the process.
00:51:57
Ksera Dyette, Psy.D. (she/her)
Right. And so um just thinking of like another example, know, you know Psychological assessment, which is something that I offer, is actually reimbursed at a significantly lower rate than psychotherapy.
Insurance Rates and Service Decisions
00:52:18
Blanca Torres, LMFT
I'm surprised by that.
00:52:20
Ksera Dyette, Psy.D. (she/her)
Yeah.
00:52:23
Ksera Dyette, Psy.D. (she/her)
Yeah. So those of you who need assessments and are wondering why these wait lists are so damn long, right? It's because more and more people are dropping out of offering assessments Because it just, like, the amount of labor is not commensurate with the reimbursement.
00:52:41
Blanca Torres, LMFT
Right. I'm guessing they pay you for the hours you see the client, not the 40, 50, 60, 70, 80 page reports you're writing.
00:52:48
Ksera Dyette, Psy.D. (she/her)
Mm-hmm. Mm-hmm. I mean, if your reports are that long. um I say that because like learning about therapeutic assessment has helped me reimagine my reports so that they are also more sustainable for my business.
00:53:00
Blanca Torres, LMFT
Oh, good.
00:53:01
Ksera Dyette, Psy.D. (she/her)
um That's a whole different conversation and topic. um But yeah, I mean, you're not guaranteed that they're going to reimburse you for all the time you spent in face-to-face testing.
00:53:12
Ksera Dyette, Psy.D. (she/her)
And they have certain numbers where it's like, if it exceeds this amount of time, they're not likely to pay. or if they do pay you you run a higher risk of being audited later on and owing them money if they think that maybe there was an error on your end as a provider.
00:53:30
Ksera Dyette, Psy.D. (she/her)
So like um sometimes I'm making decisions in my business that will know I can't offer the service at this time. For with using insurance because it's just not financially sustainable for me.
00:53:46
Ksera Dyette, Psy.D. (she/her)
Right. um But that's why I'm also teaching people like about renegotiating their rates and how to do that and what it looks like in that process, because we shouldn't have to make those decisions.
00:53:58
Ksera Dyette, Psy.D. (she/her)
We really shouldn't.
00:53:59
Blanca Torres, LMFT
Great. Right.
00:54:00
Ksera Dyette, Psy.D. (she/her)
um It should be sustainable in the first place, but a lot of clinicians don't know how to renegotiate their rates. They don't know that they can.
00:54:09
Blanca Torres, LMFT
right
00:54:09
Ksera Dyette, Psy.D. (she/her)
They don't know how to go about putting the letter to ask for it. They don't know how to go about putting together countering objections or that they can even counter objections. There's so many of these things that go into the the business part that um for me is worth putting in the effort to make sure that I'm offering a service that is sustainable financially for me, but also still remains accessible to the people that I work with. But it also has meant cutting down on my therapy
00:54:40
Ksera Dyette, Psy.D. (she/her)
offerings significantly um because I'm like, I'm not going to continue getting underpaid while I
00:54:50
Ksera Dyette, Psy.D. (she/her)
You know, i need to be able to pay my medical bills and all of these different things. And so, but those decisions can feel really hard and very painful to do because it does mean that you're maybe ending relationships with folks as a result.
00:55:07
Ksera Dyette, Psy.D. (she/her)
So I think going back to your point of nuance, it's not just nuance, it's dynamic.
00:55:14
Blanca Torres, LMFT
Yeah.
00:55:15
Ksera Dyette, Psy.D. (she/her)
um and constantly changing as a result of our own sort of personal circumstances. So.
00:55:22
Blanca Torres, LMFT
Yeah, absolutely. Absolutely. And I think if I've learned one thing in my journey to today is just to be open to things about my business changing.
00:55:37
Ksera Dyette, Psy.D. (she/her)
Yes.
00:55:38
Blanca Torres, LMFT
the and And right now it's working really well what I'm doing or at least well enough. I'm making a big life change soon, depending on how that goes.
00:55:49
Blanca Torres, LMFT
Maybe so will my business plan, right? And then that'll change and then so will my business plan again. So I think it's just about, i think being open and being dynamic, as you said, being dynamic about it.
00:56:02
Ksera Dyette, Psy.D. (she/her)
yeah yeah and open communication because we're not taught how to talk about the money aspect of our business with our clients um and it's possible to do that in a way that is caring and intentional and isn't making the client responsible for the decisions that you have to make, right?
00:56:24
Ksera Dyette, Psy.D. (she/her)
But that you know that the decisions you make impact them and how, and that they impact you as well, right?
00:56:25
Blanca Torres, LMFT
Yeah. Right.
00:56:29
Blanca Torres, LMFT
yeah
00:56:33
Ksera Dyette, Psy.D. (she/her)
I just had a money conversation with the client where I'm like, you know, I'm okay with this arrangement, but I still need to get paid before I'm able to offer more services because I'm not going to have you rack up a debt with me, right?
00:56:48
Ksera Dyette, Psy.D. (she/her)
And I'm also not going to feel good doing my work if I'm worried that I'm not going to get paid like and just being honest about that right and not in a punitive way right but a caring way with attention to how capitalism is playing a role in our relationships in the ways that I ultimately wish it didn't have to okay but yeah
00:57:13
Blanca Torres, LMFT
Yeah.
00:57:16
Blanca Torres, LMFT
Yeah.
00:57:17
Ksera Dyette, Psy.D. (she/her)
So there's so much in this topic. Was there anything else on your mind, Blanca?
00:57:22
Blanca Torres, LMFT
So much.
00:57:26
Blanca Torres, LMFT
ah I mean, I think I just want to normalize that money conversations are really hard.
00:57:33
Ksera Dyette, Psy.D. (she/her)
Yeah.
00:57:33
Blanca Torres, LMFT
And like you said, we're not taught it. We're not taught it in school. You may or may not pick it up in supervision. i think I did a little bit, you know.
00:57:45
Blanca Torres, LMFT
um But at the end of the day, you know, no matter what we talk about, what what topic we talk about, like how or when or talking to clients about this or that, ah just always come back to the reality that at the end of the day, yes, it's a therapeutic relationship and there's boundaries, but it's a relationship nonetheless.
00:58:05
Ksera Dyette, Psy.D. (she/her)
Mm-hmm. Mm-hmm.
00:58:06
Blanca Torres, LMFT
it's a It's still two human beings sitting together.
00:58:11
Blanca Torres, LMFT
And so sometimes it's you just have to just come back to that and say, hey, listen, ah want to support you. i want to be here for you.
00:58:23
Blanca Torres, LMFT
i also need to be paid. so What can we do? How can we figure this out together? I don't know. I'm not saying say those words. I'm just highlighting that at the end of the day, it's still huge two humans working together. um And as scary as that is, for me, it also bring it makes it less scary. Like for for you, it might make it scarier.
00:58:45
Blanca Torres, LMFT
For me, it makes it less scary. Because I know there's a human being in front of me who understands the realities of capitalism, at least the clients I've had, and understand that regardless of how much I love this, I need to pay rent.
00:59:02
Blanca Torres, LMFT
I need to buy food. I need to pay for my licensing fees and all these other things. So, yeah.
00:59:08
Ksera Dyette, Psy.D. (she/her)
yeah well and what I appreciate you about about you naming human part of this is that like we've we've mentioned this in another episode but like the human gets trained out of us in the way we're trained.
00:59:23
Blanca Torres, LMFT
Right. Right.
00:59:26
Ksera Dyette, Psy.D. (she/her)
And so when you think about it, these conversations actually feel hard.
00:59:26
Blanca Torres, LMFT
right
00:59:32
Ksera Dyette, Psy.D. (she/her)
don't want to say for no good reason, right? Because we are also bringing money trauma to the table that make these conversations harder, I think, some of us anyway.
00:59:43
Ksera Dyette, Psy.D. (she/her)
um But I do think that there's an aspect to which, because that goes unaddressed in our training, We're not adequately prepared to have these conversations in a liberatory way that balances the awareness that like we can't escape the influence of capitalism on our businesses, but we could try to be as anti-capitalist as we could possibly be
01:00:07
Blanca Torres, LMFT
right
01:00:08
Ksera Dyette, Psy.D. (she/her)
And what does that mean? What does that look like? And I think, you know, um we've talked about some of the models and the ways that we approach this, and it is not perfect, right?
01:00:19
Ksera Dyette, Psy.D. (she/her)
Like, perhaps we could achieve more perfection if we were totally divested from insurance and all of this. But like, the end of the day, we're still collecting money for a service that is influenced by all of these external capitalistic factors that we just can't control, that these things are present.
01:00:36
Blanca Torres, LMFT
Yeah.
01:00:39
Blanca Torres, LMFT
Yeah.
01:00:39
Ksera Dyette, Psy.D. (she/her)
So, yeah.
01:00:40
Blanca Torres, LMFT
In a perfect world, in in the world I want, I'd be smoking a joint on the beach, eating a mango, and you'd come to me and talk to me because you have a problem. And then you might hand me another joint or another mango, and then we'd go about our days.
01:00:49
Ksera Dyette, Psy.D. (she/her)
Yes.
01:00:53
Blanca Torres, LMFT
But that's not the world we live in because we decided to invent capitalism.
01:00:54
Ksera Dyette, Psy.D. (she/her)
Yes.
01:00:59
Blanca Torres, LMFT
Ha ha ha ha
01:01:03
Ksera Dyette, Psy.D. (she/her)
and In my perfect world, Blanca. And some people are doing this, which I love. And maybe I'll get there. I would play a video games with my clients. And yeah.
01:01:12
Blanca Torres, LMFT
Oh, you can absolutely, I think you should look into how to do that.
01:01:16
Ksera Dyette, Psy.D. (she/her)
I know people are doing it. I know there are like game therapy groups and things like that. But um yeah.
01:01:23
Blanca Torres, LMFT
Yeah.
01:01:23
Ksera Dyette, Psy.D. (she/her)
I'm getting there. If y'all want to see that, let me know.
01:01:28
Blanca Torres, LMFT
We want to see that.
01:01:28
Ksera Dyette, Psy.D. (she/her)
Maybe not as my client. Because like that would be too many people to manage. Yeah. but we'll get there.
01:01:35
Blanca Torres, LMFT
Called to gaming.
01:01:37
Ksera Dyette, Psy.D. (she/her)
Called to gaming, yes.
01:01:39
Blanca Torres, LMFT
no.
01:01:40
Ksera Dyette, Psy.D. (she/her)
and um So we want to kind of, um we'll transition to being called to our bodies, but I want you to think as we kind of close this conversation, if you're a provider has been listening to this, we want you to think about what's a money story that you carry into your healing work and in what ways that money story may be rooted in capitalism or not particularly liberation focused and how you can change that money story, both so that it benefits you,
01:02:15
Ksera Dyette, Psy.D. (she/her)
and your client as well. So with that said, let's call ourselves to our bodies.
Reflecting on Capitalism's Impact on Therapy
01:02:24
Ksera Dyette, Psy.D. (she/her)
Whatever you're feeling right now, relaxed, inspired, tense, grieving, invigorated, it is all okay.
01:02:36
Ksera Dyette, Psy.D. (she/her)
You don't need to act on any of these things. Just pause. Now bring your focus to one small point inside you, your heartbeat.
01:02:47
Ksera Dyette, Psy.D. (she/her)
You don't have to feel it right away. Just notice somewhere deep inside your heart is still beating. Steady, quiet, working for you.
01:03:00
Ksera Dyette, Psy.D. (she/her)
If you feel restlessness or tension, just let it be. Let your heartbeat become your anchor, a quiet rhythm beneath the noise. You are safe to pause You are allowed to feel what you feel.
01:03:16
Ksera Dyette, Psy.D. (she/her)
And underneath it all, your heart keeps going strong and steady. Stay with that rhythm for just a moment longer.
01:03:28
Ksera Dyette, Psy.D. (she/her)
And when you're ready, gently come back to us for a moment of joy and thriving this week. Blanca, what's your
Personal Joys and Season Conclusion
01:03:39
Ksera Dyette, Psy.D. (she/her)
moment joy and i am thriving?
01:03:39
Blanca Torres, LMFT
whoa
01:03:43
Blanca Torres, LMFT
I don't remember if I talked about this the last time we recorded. So if it's a repeat, please forgive me. But also, yay. um i got i used to i learned to cross-stitch when I was ah a teen.
01:03:58
Blanca Torres, LMFT
Yeah, I did talk about it last time.
01:04:00
Ksera Dyette, Psy.D. (she/her)
huh Yeah, that's okay.
01:04:01
Blanca Torres, LMFT
Okay.
01:04:01
Ksera Dyette, Psy.D. (she/her)
You can talk about it again.
01:04:02
Blanca Torres, LMFT
Well, I've held on to it. I'm still doing it. I've been cross-stitching and listening to audiobooks, which has brought me a lot of joy. and But in fact, I actually haven't done it in a week. And I feel very differently this week. And part of me wonders if it's because I haven't had those moments to kind of just like slow down.
01:04:19
Blanca Torres, LMFT
um And granny hobbies are just highly recommended. um So I think, you know, i'm i i guess a little human moment. I told Ksera I feel like I'm in the waiting room for grief.
01:04:33
Blanca Torres, LMFT
There's some elderly folks in my family that aren't doing well. And um so it's it's been, i' I'm not feeling myself. I'm not feeling great. um And
01:04:45
Blanca Torres, LMFT
that that's just my joy right now. My joy in thriving is just like connecting with my loved ones and then cross stitching. Right now I'm working on a project that says nap club, new members welcome but welcome with some super cute little snapping napping animals for one of my best friends um and yeah that's what that's my joy in thriving right now what about you Ksera?
01:05:11
Ksera Dyette, Psy.D. (she/her)
ah Mine is that I've been finishing more games lately which has been really nice um games has been a like was another thing that took like a hit from covid for me gaming and reading and Um, so finding space for that is really important.
01:05:35
Ksera Dyette, Psy.D. (she/her)
And I was trying to figure out yesterday, literally, which new RPG I wanted to play. um because the Final Fantasy franchise has been disappointing me for the last couple of years. And so I started this game, um Metaphor Re-Fantazio
01:05:53
Ksera Dyette, Psy.D. (she/her)
I'll put in the show notes.
01:05:53
Blanca Torres, LMFT
Whoa.
01:05:55
Ksera Dyette, Psy.D. (she/her)
Ha ha ha ha ha.
01:05:56
Blanca Torres, LMFT
Fancy. Well, that sounds a very fancy.
01:05:57
Ksera Dyette, Psy.D. (she/her)
But it's got um a lot of socio-political themes and questioning of the world and going into places where a lot of games maybe don't go.
01:06:11
Ksera Dyette, Psy.D. (she/her)
And it's interesting that I've chosen this, but like the music, like the battle music is also really fire.
01:06:12
Blanca Torres, LMFT
I love
01:06:16
Ksera Dyette, Psy.D. (she/her)
Yeah.
01:06:18
Blanca Torres, LMFT
that.
01:06:18
Ksera Dyette, Psy.D. (she/her)
I was dancing around in my kitchen to that last night. um And I'm looking forward to going and playing a little bit before I have some more work to do this evening.
01:06:31
Ksera Dyette, Psy.D. (she/her)
So yeah, that's my joy.
01:06:32
Blanca Torres, LMFT
Nice. Yeah. I love that. I think that's great.
01:06:38
Ksera Dyette, Psy.D. (she/her)
Well, um we are approaching the end of the season.
01:06:43
Blanca Torres, LMFT
Yeah, we are.
01:06:44
Ksera Dyette, Psy.D. (she/her)
So i think, I think our next episode might be our last for the season. I remember correctly, maybe, or second to last, y'all will know when it comes out, but ah thank you for sticking with us on this journey.
01:07:00
Ksera Dyette, Psy.D. (she/her)
If you haven't, um please leave a review and subscribe. um If you're listening to this episode, we have divested from the Spotify machine at this point.
01:07:11
Blanca Torres, LMFT
Yes.
01:07:13
Ksera Dyette, Psy.D. (she/her)
um And so we apologize to our Android users, but our Zencastr direct link is in our link and bio on our Instagram. And we are also on YouTube.
01:07:25
Ksera Dyette, Psy.D. (she/her)
um YouTube has its own questionable blah, blah, blah. But, you know, we've got to keep ourselves in some places.
01:07:33
Blanca Torres, LMFT
Right.
01:07:34
Ksera Dyette, Psy.D. (she/her)
ah So the least bad ones are where we are right now.
01:07:40
Blanca Torres, LMFT
Right.
01:07:40
Ksera Dyette, Psy.D. (she/her)
whatever Whatever that means. So are your reviews help. If you think it's five stars, then please give it five stars and don't just think about it. And we'll see you next time.
01:07:50
Ksera Dyette, Psy.D. (she/her)
All right.
01:07:51
Blanca Torres, LMFT
Yeah. See you next time.
01:07:52
Ksera Dyette, Psy.D. (she/her)
Okay. Bye.