Red Flags to Consider When Joining a Mental Health Therapy Practice
Mental health professionals all seem to have a horror story about less-than-ideal leadership and work environments while earning hours toward independent licensure. We’ve talked about it, though rarely out loud, out of fear - fear of confrontation and setting boundaries. We've thought about the distressing state of our profession, questioning how it deteriorated to such a degree (I blame neoliberalism). We had expectations of nurturing, understanding supervisors, only to wonder, “How are these people therapists!?”
I would likely be unemployed had I not created my group practice, as I often was considered an awkward, defiant troublemaker. Now, I put much of my available resources into rescuing others from these oppressive systems and bringing them to a healthier, more supportive professional environment. I believe in a collective, communal effort to support our peers in this endeavor, forming networks that can provide an escape from toxic work environments.
Unfortunately, many newcomer therapists are unaware they are being exploited and harmed. They might believe these environments are “normal” and just stick it out, perhaps even be thankful for the opportunity. They may overlook better opportunities, hindering their personal and professional growth, so it is crucial to recognize unhealthy work environments.
I’ve met individually with therapists and listened to their experiences for over a decade, and I believe I have some insight into the cautionary signals to watch for when joining an agency or group practice. I hope to inform therapists so that they don’t tolerate it and get out. We’ve been there, and it doesn’t have to be that way. Being a therapist can be the fulfilling career you envisioned.
Here are my red flags to consider when joining a mental health therapy practice.
Workplace Culture and Dynamics
Viewing other organizations/groups as competition
Minimal collaborative effort with other agencies or practices. The efforts in place seem performative, the relationships inauthentic.
The organization exhibits a philosophy of self-interest instead of abundance. The more we argue that humans are self-interested, the more self-interested we become. If we want to be prosocial but believe others are selfish, we are less likely to take the risk of contributing to the welfare of others and much more likely to focus on getting our own needs met.
Purposes like “being the best” or “dominating the market” are implied or explicitly stated. There is an overemphasis on “best in class” or “world-class” and other forms of self-aggrandizing. These phrases show a desire to win over competitors rather than to contribute to the community.
Leadership exhibits fear of losing clients to competitors, so few referrals are sent outside of the agency/group. Client care is not the priority, and profits are emphasized.
Efforts are made to maintain low employee pay to ensure higher profits
Minimal Transparency about pay. You are asked not to discuss your pay with others at the practice/agency. You likely feel undervalued for the work you perform.
Billing is hidden, so you are unsure how much revenue you generate. Questions about revenue are met with significant resistance.
Leadership publicly complains about associates advocating for higher pay, which echoes the classic class conflict between the proletariat and bourgeoisie.
Credentialing fees are expected to be paid back if you attempt to leave the practice. This is absurd, considering it takes me under an hour to credential therapists with all our payers. It's interesting how overvalued the credentialing process is, as I’ve had billers send offers to credential me for $200 per contract.
Non-compete agreements are required to ensure you don’t take clients with you. They suggest you cannot take clients with you, which is unethical (conflict of interest).
Clients are moved off your caseload when you put in your notice. They focus on client retention for profit rather than on client welfare. They treat clients as commodities.
Unpaid interns comprise much of the workforce.
Fear-based work environment and lack of effective communication
Managers coerce staff rather than facilitate.
Vitality and creativity are dampened because your behavior is controlled by fear of retribution, compliance, and the need to seek the approval of authorities.
You feel scared, walking on eggshells with leadership.
You feel silenced and too scared to ask for support. You cannot make suggestions to improve the company. There is no 360 feedback.
Employees are publicly shamed during group supervision/consultations. Fear and shame are used as mechanisms for change.
Policies are unclear or non-existent. They may be confusing and frequently changing. It’s challenging to keep up, and you are blamed if you can.
Overemphasis on a hierarchical structure in the organization
Top-heavy organizational structure. There is more management and support staff than practitioners.
Lack of humility from leadership. They act as the experts and don’t seem open to learning from associates and interns. They may even talk down to employees. They gossip about those perceived as “less than.”
Leadership is not comprised of therapists. The organization is owned and operated by non-clinicians or investors.
Supervision and Professional Development
Absence of clear supervisory agreements and contracts
There is no supervisory agreement or contract.
Expectations of the supervisory relationship are unclear.
Supervisor Reputation
What’s the track record of other therapists getting licensed under their supervision?
Where are past supervisees, and what is their level of success? Explore the lineage of your supervisor.
What sort of relationship does your supervisor have with past supervisees?
What do others in the community say about your supervisor?
Your supervisor is unable to communicate their supervisory approach
What is their model of supervision?
What is their managerial style?
Your supervisor does not have documentation of their status with the board
Has your supervisor completed the required training to supervise?
Is your supervisor on the registry?
Inadequate supervision and investment in associate development
Minimal supervision (one hour monthly for compliance) is provided. Additional time is rarely considered.
Your supervisor is rarely available for consultation.
Your supervisor has not observed you conduct a therapy session.
The quality of supervision notes is poor.
The supervision note is thoughtless, with minimal written, personalized feedback.
Supervision notes are not completed in a timely manner and are out of compliance.
You are expected to write the supervision note (this is the expectation of the supervisor, not the supervisee).
The quality of supervision sessions
Your supervisor seems distracted during supervision.
Supervision sessions often do not start on time or end early.
Minimal feedback is provided.
The depth of discussion is minimal.
Your supervisor is not active or interested in your development
You are rarely provided adequate resources to improve your practice.
Your supervisor tries to suppress your growth and development.
There is minimal exploration of your values, strengths, personality, and learning style.
Your supervisor may quickly suggest talking with a therapist when bringing up a personal issue rather than responding with empathy, suggesting that bringing any problems into the supervisory relationship is inappropriate.
Strong emphasis on compliance with supervisor expectations rather than a collaborative approach
The supervision model is a top-down, micromanagement approach.
360 feedback is discouraged.
You feel like a subordinate.
Your expertise/knowledge is often questioned or invalidated.
You are negatively compared to other therapists.
Your supervisor uses a militant approach of fear to motivate you, including frequent critiques (sometimes personal), threats to your license/job, and a sense of urgency to improve (rather than a developmental approach).
Emotional Well-Being and Burnout
Emphasis on productivity and billing
Productivity is the primary metric by which you are evaluated. Other metrics are hardly considered in your reviews. If the expectation is thirty sessions or more per week, that is too much, and you likely will burn out.
The focus is on maximizing billing. You likely have frequent meetings about how to achieve billing goals.
Case mix and complexity are not considered in your productivity evaluation. The difficulty and emotional strain of your caseload is not considered.
Documentation expectations are unrealistic, such as submissions of all notes by the end of the business day. This is especially problematic when combined with high productivity expectations.
Disregard for personal needs
Minimal flexibility in your schedule is allowed.
Your hours, schedule, and caseload are micromanaged.
Clients are placed on your caseload without your consideration. The expectation is that you are assigned a caseload rather than building one based on your skill set and client needs and preferences.
Work-life balance is talked about but not practiced.
Critique for emotional expression
Masking/concealing of emotions and individual identity is suggested.
Management critiques your appearance. This may include critiques about how you dress, style your hair, groom, posture, makeup, etc.
Personal emotions, particularly those considered volatile or negative, are expected to be left at home.
Burnout at the organization
Teammates openly talk about how they are burnt out.
There is frequent, performative talk about burnout management (especially on public forums and social media), yet minimal support for those experiencing it.
Employees are frequently absent due to illness/mental health-related issues and burnout.
Employees are thankful when clients cancel.
Employees are often behind on their notes due to the workload.
There is a high turnover rate in the organization. You may hear this from clients or colleagues.
Ethics
There is pressure to compromise ethical standards
You may feel gaslit by leadership about your concerns about ethical breaches.
Your company asks you to write reviews for them, or they ask for reviews from your clients (possibly offering incentives such as free sessions), which is unethical (conflict of interest/professional boundaries/client coercion).
Leadership encourages clinicians to keep clients on their caseload longer than clinically necessary to ensure productivity numbers.
You are often expected to practice outside of your competency area.
You are assigned cases where you don’t have adequate training and may cause harm to the client.
The organization engages in fraudulent billing practices.
Check how claims are being submitted. Who is it billed under? Does the insurance company allow this? How do you know?
Claims are submitted before notes are signed and locked.
Security measures are not followed
Protected Health Information (PHI) is transferred with no encryption.
You are encouraged to use your personal cell phone/email to communicate with clients.
Client information is openly discussed and shared with no clinical purpose.
Informed consent is not properly secured
Consent not obtained prior to starting therapy.
Consent documents may be disorganized or missing key components required by the board.
Consent and assent are rarely discussed at the organization.
Referrals
There appears to be a conflict of interest when referrals are made, such as practice owners receiving commissions, rebates, or remuneration in exchange for client referrals.
Clients are terminated when fees create undue hardship without assistance in locating comparable services.
Diversity and Inclusion
Lack of inclusivity and cultural competence
The organization does not proactively promote inclusivity, which diminishes the value of diversity and compromises the safety and comfort of expressing marginalized identities.
The organization avoids providing therapy to marginalized identity groups. They may refuse services to individuals based on identity, such as transgender or autistic persons, under the pretext of "lack of training." This stance marginalizes these groups further and abdicates the organization's responsibility to seek necessary training and education to serve all communities effectively.
You feel shamed and disempowered from systemic oppression at the workplace.
Discriminatory practices and microaggressions
There is frequent negative commentary or mocking of neurological differences.
Discriminatory remarks about oppressed groups and clients are common.
Consultations frequently denigrate into criticisms and mocking of clients, undermining the professionalism and empathy expected in therapeutic settings.
Microaggressions contribute to a hostile and unwelcoming workplace atmosphere, further entrenching discrimination and exclusion.
Performative politics without genuine behavior to effect change
There is a mismatch between rhetoric and reality about social justice issues. You’ll see all the buzzwords on the organization’s website, but these concepts are rarely discussed during supervision or training.
The organization exploits activism symbols, including those related to neurodiversity, LGBTQ+ rights, and the Black Lives Matter movement, for profit without a deep understanding of or commitment to the values these symbols represent.
Uncomfortable conversations about diversity and inclusion are avoided.
Feedback from marginalized groups is dismissed as too radical, niche, or unimportant.
Final Thoughts
The intention of this post is to inform therapists, who may be unaware, of potentially harmful work environments. While some readers might scoff or feel attacked, my aim is to extend an invitation to enhance our roles as leaders and mentors. We often find ourselves acting as gatekeepers of our profession, yet we sometimes lose sight of our true purpose: to foster growth in ways that reflect the values and integrity that render this work so meaningful. Many of us have navigated unnecessary hardships, perhaps even considering them a rite of passage. However, let's reframe our histories of cautionary tales into narratives of empowerment, resilience, and shared triumph. Let's commit to smoothing the path for those who follow, ensuring our legacy is one of nurturance and compassion.
