Launching a New Practice

My practice of psychology is expanding beyond the transactional.

I feel compelled to integrate all that I have learned in the last two years, from the ongoing protests in Portland to calls to defund the police to the spotlight that social media has shined on the violence perpetrated against transgender, especially trans BIPOC (Black and Indigenous People of Color). Taken as a whole, along with enduring social justice movements like #metoo and Black Lives Matter, these initiatives have exposed the nested systems of oppression that make up our society.

These systemic problems even affect health care, education, and other human services that we consider a “common good.” When we force these human services to adopt a business model of profit and loss, we lose the humans on both sides of the equation. Hospitals that must turn a profit and school systems that are organized around producing “results” reduce the students, families, patients, and parents to consumers. And we ignore the needs of the generous people who help, teach, and save lives.

We can’t change all of that but we CAN shift our part of this equation. That’s why our team is moving beyond “the therapy hour,” which is a transactional model of providing support to families. Locked into a transactional model, there’s less incentive to collaborate, to create, to expand, to innovate. Also, keeping this old model alive is expensive. If your business is bound by filling hours, then you are constantly in need of getting new clients as opposed to spending your energy dedicating your full focus to the clients you serve.

Billing by the hour builds silos and produces a disincentive to collaborate. The goal of engagement should be to solve your client’s problems. Supporting real growth, we help families to become expansive, which is both cost-efficient and provides the connection that families really need.

In our model, we are not spending time worrying about whether the hour was paid for or who is going to come back to book next week. We’re committed, we’re all in, and we offer all of our resources to the family. And our client families have committed and paid upfront, making all the hours and the scheduling incidental not central. You can read more about the importance of commitment in our model here.

Relying on the billable-hour model has always made me uncomfortable. Families are forced to find ways to get help within the restrictions of Managed Care. I receive several calls each week and help families to find psychologists who take their insurance.

The families who decided to work with me as an “out of network” provider were still constrained by the Managed Care model, a version of the billable hour. I would join with them to meet the requirements for reimbursement and “play the game” as their ally. We worked together to help them solve their problems but the scope of our work was still constrained. We were forced to use our limited time to focus on one aspect of their family dynamic. Even in private practice, this felt like triage work.

Now that I see the nested systems of oppression that underly the care that I provide, I cannot continue to play the same game. My mission to elevate parents and support them to create positive family cultures has brought me to a precipice.

Even if we admit defeat and bow to the dehumanizing impact of a capitalist system, how can we treat families as commodities?

We need to lift up the parents who dare to nurture their family cultures, the “gardens,” in which our future leaders, innovators, and heroes are grown and raised. We need more models of these families and we need to create systems to support them.

photo credit: Andrew Rice/Unsplash


P.S. Adapting the arguments from Tim Williams’ “An Obituary for the Billable Hour” to our new practice model, we demonstrate how billing by the hour:

  • misaligns the interest of the professional and the family. The professional wants more hours, and the client wants less hours.
  • focuses on our efforts, and the parts of what we provide (inputs and the hours and the cost and activities), instead of what the client really wants: outputs and results.
  • places all of the transaction risk on the client. They’re buying something from us with no recourse for their sale. This power dynamic eliminates any real grievance process, so the client is left to trust that what they’re buying is going to produce for them.
  • fosters a mentality of production instead of an entrepreneurial, collaborative spirit. There is a relational space between the client and the professional that is avoided and muted in a transactional model.
  • locks us both into a zero sum game, a production mindset that can be accounted for on a spreadsheet, not the kind of expansion that we want to show our families how they can create.
  • penalizes any advances that we make in our effectiveness. The faster that we can solve a problem if we’re billing by the hour, based on greater expertise, the less we earn.
  • commoditizes our talent and intellectual capital into a unit of time, which really reduces our ability to differentiate ourselves from the competition. We become a commodity that bills for our time at one fee or another. It doesn’t actually note how we are different and what we can provide.
  • places an artificial ceiling on what we can earn, because there are only so many hours in a day and days in a week.
  • rewards busy-ness, and utilization, instead of effectiveness and accountability. For that hour, we show up and we’re here to use us as you want, but it’s not about partnering with the family to create something more effective, or to be accountable to them and their commitment to us.
  • discourages innovation. If we’re constantly stuck in the measurement of time, our motivation is to be billable, and to add more hours, not to innovate and make those hours more effective.
  • provides no useful information about what really matters, such as the quality of the work, or the satisfaction of the family, or the effectiveness of our approach, or what the family can achieve. We limit our full engagement to what happens in the 60 minutes when our meter is ticking.
  • incentivizes us to allocate our resources in the wrong direction. Instead of assigning talent that can most effectively solve the problem, we’re incentivized to assign an associate who bills for their time at a lower rate. This equation compels the professional to provide less skilled, less experienced people to do the work because the client is paying the same amount. The professional is incentivized to give the client less in order to maximize the profit margin for that hour.