PsyD - Do you regret graduating with a PsyD

[WisNeuro]

But here's the rub. Even in fully funded PhD programs, trainees who have no backup or safety net can find themselves accruing debt when reasonable expenses (medical bills, professional travel, housing) outpace their stipends. All sorts of things can tip the balance of income and expenses. I personally agree with the White Coat Investor's advice about loan to income ratio and have lived within it. Telling people that it's possible to - or that they ought to - graduate totally debt-free tacitly assumes a few things: (a) they have a safety net or a consistent additional source of income, (b) nothing bad will happen to them or close family members while living on a graduate stipend, and/or (c) the stars align and the advice of "aim for a low COL area" does not conflict with "go to whatever funded program you can get into."

It does not assume that at all. For the anecdotes here, I can supply many of my own, myself included that did not have a safety net, did not have parents paying for undergrad or grad school, and did have things happen while in grad school that posed financial challenges (car issues, surgeries, etc). I agree that when we look at the group differences, we see plenty of that, but I bet a good deal of variance is soaked up in those who choose the diploma mills simply because they didn't want to seek out volunteer research opportunities, or take the time to beef up their CV. I'm all for changing aspects of the system, but not at the cost of infantilizing people.

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[R. Matey]

From the 2018 APPIC applicant survey:

"Please estimate the total amount of DEBT that you have accrued to date as a consequence of attending GRADUATE SCHOOL IN
PSYCHOLOGY, including tuition, fees, living expenses, books, etc. Please include all forms of debt such as student loans, credit cards, personal loans, etc. Please do NOT include undergraduate debt or debt that is unrelated to your graduate training."

Mean = $ 91,750 Median = $60,000
SD = $103,957

$0 582 27%
$1 - $9,999 116 5%
$10,000 - $19,999 110 5%
$20,000 - $29,999 79 4%
$30,000 - $39,999 58 3%
$40,000 - $49,999 56 3%
$50,000 - $59,999 66 3%
$60,000 - $69,999 60 3%
$70,000 - $79,999 48 2%
$80,000 - $89,999 70 3%
$90,000 - $99,999 48 2%
$100,000 - $149,999 277 13%
$150,000 - $199,999 204 9%
$200,000 - $249,999 176 8%
$250,000 - $299,999 96 4%
$300,000 - $349,999 63 3%
$350,000 - $399,999 22 1%
$400,000 or higher 41 2%

The distribution is pretty binomial. I think the typical person I've seen on SDN who wants a Psy.D. either didn't know that funded Ph.D. programs existed (this guy) or didn't want to slum it in a fly-over state for a few years (also this guy). That said, it was entirely possible for the majority of this sample to go to graduate school either debt free or end up tolerating a reasonable amount of debt. 40% of student debt here starts at over $100k

 

[deleted343839]

I don't know that we disagree. Expensive PsyD programs exist to perpetuate well-heeled mediocraty. The reason they are in expensive cities is because benefactors (family,spouses) can afford to pay the entry fee. I certainly could not afford to pay the fees they ask.

I don't know that anyone is saying that you need to have no loans, but I have followed the rule WCI espouses and it worked out for me. It did mean moving to several less desirable locales, taking side jobs for cash, and some help from family as well.

One of the reasons medicine is so diverse is that the salaries justify the loans. Nursing even more so in this regard. Until we fix the low salaries, diversity will be hard because it is more of a risk.

There's a great book called Lower Ed by Tressie McMillan Cottom that does a deep dive into the for-profit education industry. Although it focuses more on undergraduate education, it does not support the idea that for-profits are going out of their way to target people with money to burn. But anyway, we're not talking about rich people. This thread has focused on people who've taken on untenable amounts of student debt in expensive PsyD programs. Those people are decidedly not well-heeled, and yet I suspect that they make up a large proportion of PsyD students.

Other than the issue of for whom PsyD programs exist, I don't think we disagree either. I do wish the discussion were less black and white about debt. That most people (if any) should be taking out $200K+ in loans for a PhD or PsyD is not really that controversial (even if uninformed prospective applicants on here want it to seem that way). I don't many psychologists on here arguing in favor of taking on that amount of debt. But more manageable debt loads (along the WCI rule, for example) are a lot more justifiable and don't warrant the flack.

The financial math for the medical field is also substantially different than it is for psychologists. From start to finish a PhD in clinical psychology is something like 7 years. Then, when we come out we're looking at median salaries of $90k. MDs take a little more than half as long, and median salaries are over twice as large. There are numerous other ways that the MD : PhD comparison isn't a good fit, but I think the financial math also makes it very clear that we (unfortunately) are working with a much more complicated system to re-jigger if we want to improve equity of access to the professional education/degree.

Of course none of this comes down to one factor. But if we set aside the expensive PsyD programs and look at funded PhD programs, I think it is reasonable to ask why those programs are also not attracting a more socioeconomically diverse student body. Essentially free school and a median $90K salary at the end of it isn't such a terrible deal in the hypothetical. (By the way, it takes at least 7 years for most MDs to start earning serious money because a residency is expected - I wouldn't mind psychology moving to a similar training model though that is unlikely to happen.)

My take is that a relatively privileged background is conducive to tolerance for years of low pay and uncertainty in the employment market, and those who might have a greater sense of urgency for financial and employment stability are just really damned inconvenient for the field.

 

[R. Matey]

But if we set aside the expensive PsyD programs and look at funded PhD programs, I think it is reasonable to ask why those programs are also not attracting a more socioeconomically diverse student body. Essentially free school and a median $90K salary at the end of it isn't such a terrible deal in the hypothetical. (By the way, it takes at least 7 years for most MDs to start earning serious money because a residency is expected - I wouldn't mind psychology moving to a similar training model though that is unlikely to happen.)

My take is that a relatively privileged background is conducive to tolerance for years of low pay and uncertainty in the employment market, and those who might have a greater sense of urgency for financial and employment stability are just really damned inconvenient for the field.

First gen college student here-It's because I didn't know they exist. Literally, if it wasn't for SDN, I would've attended an unfunded Psy.D. program. I didn't know there were other options. No one told me that Ph.Ds for clinical/counseling/school psychology are funded. I went to an R1 for undergrad, but I was a face in a sea of faces. None of my professors told me about funded Ph.D. programs and my master's professors strongly discouraged me from pursuing psychology (thankfully I didn't listen). But, I actually believed that the path to doctoral education was bachelors, master's, Psy.D./Ph.D. And I thought debt was just part of it. There's a massive career education problem in undergraduate education. I think many people don't know what opportunities exist and/or how to access them.

Personally, I didn't mind taking a lower salary if it mean't the chance that I could have a higher one later. The qualitative difference from going to high COL area with an LPC salary to a low COL area with a grad school salary wasn't a drastic one. As far as what you wrote, I'd actually wager the opposite: that first gens would be more likely to take this kind of deal than someone who has grown accustomed to a certain lifestyle and want a quick way to pay for it. My guess is that this, like the distribution I posted above, is binomial.

 

[Sanman]

There's a great book called Lower Ed by Tressie McMillan Cottom that does a deep dive into the for-profit education industry. Although it focuses more on undergraduate education, it does not support the idea that for-profits are going out of their way to target people with money to burn. But anyway, we're not talking about rich people. This thread has focused on people who've taken on untenable amounts of student debt in expensive PsyD programs. Those people are decidedly not well-heeled, and yet I suspect that they make up a large proportion of PsyD students.

Other than the issue of for whom PsyD programs exist, I don't think we disagree either. I do wish the discussion were less black and white about debt. That most people (if any) should be taking out $200K+ in loans for a PhD or PsyD is not really that controversial (even if uninformed prospective applicants on here want it to seem that way). I don't many psychologists on here arguing in favor of taking on that amount of debt. But more manageable debt loads (along the WCI rule, for example) are a lot more justifiable and don't warrant the flack.



Of course none of this comes down to one factor. But if we set aside the expensive PsyD programs and look at funded PhD programs, I think it is reasonable to ask why those programs are also not attracting a more socioeconomically diverse student body. Essentially free school and a median $90K salary at the end of it isn't such a terrible deal in the hypothetical. (By the way, it takes at least 7 years for most MDs to start earning serious money because a residency is expected - I wouldn't mind psychology moving to a similar training model though that is unlikely to happen.)

My take is that a relatively privileged background is conducive to tolerance for years of low pay and uncertainty in the employment market, and those who might have a greater sense of urgency for financial and employment stability are just really damned inconvenient for the field.

I am actually familiar with the book Lower Ed and have read and watched much about for-profit education. If you look at for-profit school such as DeVry and Strayer, they are often located closer to the poor parts of the city or working class suburbs and aimed at those that want a job. There were a lot nursing (LPN) and medical tech programs that focused on lower SES folks looking for a job. Those people are not looking to spend 10 years in school and they are pitched career focused training that is often sub-par.

When you look at the ubiquitous PsyD programs in NYC, DC, CA, Chicago, etc, I believe these are targeting a different sort. These are targeting richer folks and it is not just for-profit schools. Stanford-PGSP, GWU, NOVA are going for these people too. The upper middle class folks that are willing to pay up for their child to become a doctor and stay in the upper middle class are there. The folks the schools I attended college and grad schools with could never afford to pay their way through, but I interned and worked with several people that had family pay their full freight to PsyD schools.

If you look back at my posts, I have always posted the 1x rule for would be students for masters or doctoral programs. We are in agreement there.

As for priveleged background leading to tolerating years of low pay I have to agree. I have a family member in residency now that drives a beater and has struggled to pay bills while many med school colleagues have new cars and parental major parental help in securing apartments, furnishing, etc. The truth is the truly low SES could never even afford to pay for grad school application fees, flights for interviews, nice clothes, and the other requirements to make it through grad or med school. It is one of the reasons I no longer recommend it to many of limited means. Nursing and social work have systems in place that allow one to work up the ladder and self-fund an education. I once worked with an NP at an LTC building where she started as a CNA nearly 40 years earlier. She worked her way up from nursing assistant, to med tech, LPN, RN, and then NP. She worked and self-funded her education the whole way. That just is not possible in our field.

 

[futureapppsy2]

From the 2018 APPIC applicant survey:

"Please estimate the total amount of DEBT that you have accrued to date as a consequence of attending GRADUATE SCHOOL IN
PSYCHOLOGY, including tuition, fees, living expenses, books, etc. Please include all forms of debt such as student loans, credit cards, personal loans, etc. Please do NOT include undergraduate debt or debt that is unrelated to your graduate training."

Mean = $ 91,750 Median = $60,000
SD = $103,957

$0 582 27%
$1 - $9,999 116 5%
$10,000 - $19,999 110 5%
$20,000 - $29,999 79 4%
$30,000 - $39,999 58 3%
$40,000 - $49,999 56 3%
$50,000 - $59,999 66 3%
$60,000 - $69,999 60 3%
$70,000 - $79,999 48 2%
$80,000 - $89,999 70 3%
$90,000 - $99,999 48 2%
$100,000 - $149,999 277 13%
$150,000 - $199,999 204 9%
$200,000 - $249,999 176 8%
$250,000 - $299,999 96 4%
$300,000 - $349,999 63 3%
$350,000 - $399,999 22 1%
$400,000 or higher 41 2%

The distribution is pretty binomial. I think the typical person I've seen on SDN who wants a Psy.D. either didn't know that funded Ph.D. programs existed (this guy) or didn't want to slum it in a fly-over state for a few years (also this guy). That said, it was entirely possible for the majority of this sample to go to graduate school either debt free or end up tolerating a reasonable amount of debt. 40% of student debt here starts at over $100k

This question does specifically exclude things like credit card and medical debt, though, so it doesn't cover the types of circumstances that @MamaPhD mentioned,

 

[futureapppsy2]

The financial math for the medical field is also substantially different than it is for psychologists. From start to finish a PhD in clinical psychology is something like 7 years. Then, when we come out we're looking at median salaries of $90k. MDs take a little more than half as long, and median salaries are over twice as large. There are numerous other ways that the MD : PhD comparison isn't a good fit, but I think the financial math also makes it very clear that we (unfortunately) are working with a much more complicated system to re-jigger if we want to improve equity of access to the professional education/degree.

Physicians also have residency/fellowship after medical school, which is between 3-7 years or so depending on the specialty (3 for primary care, 4-7 for everything else), which is basically slightly better than postdoc-esque pay and much worse hours. The numbers still work out in their favor much more, but it's a bit of a mischaracterization to say that physician training is only four years.

 

[deleted343839]

As far as what you wrote, I'd actually wager the opposite: that first gens would be more likely to take this kind of deal than someone who has grown accustomed to a certain lifestyle and want a quick way to pay for it.

It's a testable hypothesis. There is a small literature on first gens going on to grad school but I'm not sure if any of it is psychology-specific.

When you look at the ubiquitous PsyD programs in NYC, DC, CA, Chicago, etc, I believe these are targeting a different sort. These are targeting richer folks and it is not just for-profit schools. Stanford-PGSP, GWU, NOVA are going for these people too.

You might be right, and for some older programs especially I'm open to the possibility that psychology doesn't reflect the overall trends of for-profit graduate programs. But enrollment in for-profit graduate programs increased drastically in the 2000s and into the early 2010s, and this was driven partly by more free-flowing financial aid and other federal money. This tracks with the "golden age" of Argosy, in particular.

This question does specifically exclude things like credit card and medical debt, though, so it doesn't cover the types of circumstances that @MamaPhD mentioned,

As an aside, I'm interested in how many people use low-interest student loans to replace or offset medical or consumer debt.

 

[R. Matey]

This question does specifically exclude things like credit card and medical debt, though, so it doesn't cover the types of circumstances that @MamaPhD mentioned,

Ummm...

"Please estimate the total amount of DEBT that you have accrued to date as a consequence of attending GRADUATE SCHOOL IN
PSYCHOLOGY, including tuition, fees, living expenses, books, etc. Please include all forms of debt such as student loans, credit cards, personal loans, etc. Please do NOT include undergraduate debt or debt that is unrelated to your graduate training."

 

[Spydra]

Nursing and social work have systems in place that allow one to work up the ladder and self-fund an education. I once worked with an NP at an LTC building where she started as a CNA nearly 40 years earlier. She worked her way up from nursing assistant, to med tech, LPN, RN, and then NP. She worked and self-funded her education the whole way. That just is not possible in our field.

I've thought about this quite a bit as someone from a non-privileged background nearing the end of a PhD and I'm starting to think the only reason this isn't an option in our field is because there isn't enough diversity in the positions of power to really push for this. The attitude that one can't become a researcher without sacrificing all else (and how is it really a sacrifice if privilege affords you people who take care of your needs?) in exchange for a funded program that doesn't fund nearly enough regardless of privilege/non-privileged background is just absurd. Speaking only of the self-funding the whole way, some PsyD programs seem to offer something close to what is observed in Social Work/Nursing. Some seem to be designed for students to get a licensed Master's en route (and may even require this) and then one can work in the field while completing doctoral requirements. This type of option is understandably appealing to those who have families to support, health insurance to cover, and other circumstances to consider. PhD programs could also do this (perhaps some do) and could still produce researchers, some of whom would choose the academia route. The key difference I see between the PsyD programs doing this and the PhD programs rolling their eyes at the thought is the latter is often controlled by whiteness and privilege. I have many thoughts about how to address that, but I think I have said enough.

 

[futureapppsy2]

Ummm...

Key word: related to graduate school training. So not medical debt or needing a new car or whatever.

 

[AbnormalPsych]

I know plenty of people who used student loan $ for some reallllllly unnecessary things. Things that clearly violated the agreements you sign for student loans on what that money can be used for.

 

[AbnormalPsych]

First gen college student here-It's because I didn't know they exist. Literally, if it wasn't for SDN, I would've attended an unfunded Psy.D. program.

I am also a first gen. I was super fortunate to have a mentor at my very small undergrad that really explained all this to me. And also fortunate that my dumb *** did not get into the few schools I applied to the first time while in undergrad and I only half listened to this guidance. In working as an RA at an R1 and other roles for awhile post bach I had another mentor constantly telling us that no one should have to pay for a PhD. We should be paid. Things finally clicked about what things should be like, and what the long term impacts of these decisions would be, and I am thankful for the brutal truth every day now that I am on the other side. I would be so miserable now with huge loan debt for grad school after the other sacrifices I made for/during it (even though I absolutely loved it).

 

[deleted343839]

I am also a first gen. I was super fortunate to have a mentor at my very small undergrad that really explained all this to me.

A mentor explained this to me as well. Why isn't this explained to every psychology major who expresses an interest in grad school??

Some seem to be designed for students to get a licensed Master's en route (and may even require this) and then one can work in the field while completing doctoral requirements. This type of option is understandably appealing to those who have families to support, health insurance to cover, and other circumstances to consider. PhD programs could also do this (perhaps some do) and could still produce researchers, some of whom would choose the academia route.

I agree. The field lost its way with master's-level training but I think a more stepwise model could be viable.

And yes, it could work in research. It would require a re-alignment of research dollars to compensate research staff based on their duties and % effort regardless of whether they happen to be enrolled in a doctoral program. This didn't click for me until I started working in academic medicine, where master's level research staff run most projects and earn reasonable salaries. I also think that normalizing grants, graduate fellowships, and project supplements as a way to fund a person's time while they complete dissertation-level work is also a good idea and a better way to train future scientists anyway. In my case, my dissertation fellowship salary was more livable than my graduate student stipend. Spending half your time as staff on a PI's project and/or a master's level clinician, and the other half on your own project funding, would be a lot more sustainable. There would be fewer PhDs under this funding model, and that's not a bad outcome either.

 

[R. Matey]

Key word: related to graduate school training. So not medical debt or needing a new car or whatever.

I'd wager that's a small portion of the variance in overall debt. I'm not saying that more shouldn't be done to help marginalized students. The school my department was housed in had funding mechanisms for people in financial distress and I know this also existed for students in at least one other doctoral program in counseling psychology. If I had attended a Psy.D. program, I would've been SOL if something had happened.

A mentor explained this to me as well. Why isn't this explained to every psychology major who expresses an interest in grad school??

I was told to get a master's degree by my faculty mentors, I think because they thought I just wanted to do therapy (ironically, I was a research assistant in undergrad). I know that some departments offer this as a course, but it doesn't really belong as a class. People who can't access the course for whatever reason may not be in the know. I think even listing resources on the website where students who are interested can learn more would go far.

 

[deleted343839]

I think even listing resources on the website where students who are interested can learn more would go far.

Come to think of it, this could be done in 5 minutes a semester in every introductory psychology course.

 

[PsySeeker]

I absolutely don’t regret it. This is a second career for me, and I had specific needs, namely I have little ones and my spouse has a good job that isn’t portable in the least. So it wasn’t in my interest to move. This of course required some compromises, but I was able to get into a localish university based Psy.D. program that is (was?) considered one of the top 5 or so nationally. Funding fluctuated somewhat while there due to the ongoing state budget crises, but I always had some and always had in-state tuition. I believe tuition cost me about 10k total if I count stipends against it (but not money from internship). None of that happened by accident, I had to actively shape aspects of it, but it can be done.

After paying my dues (or finished being exploited for profit) at post-doc, I formed an LLC and started working as a therapist because I prefer it to assessment after having done plenty of both. Again, it’s not a guaranteed path, but I have to say, those that say you can’t make good money doing mostly therapy as a psychologist are off base. You can, but you have to be driven, learn to market, be good at what you do, and have the capacity/willingness to work an actual full time schedule. If those things are true my experience is that therapy can provide income for a psychologist comparable to or even exceeding the average psychiatrist’s earnings.

 

[Sanman]

I absolutely don’t regret it. This is a second career for me, and I had specific needs, namely I have little ones and my spouse has a good job that isn’t portable in the least. So it wasn’t in my interest to move. This of course required some compromises, but I was able to get into a localish university based Psy.D. program that is (was?) considered one of the top 5 or so nationally. Funding fluctuated somewhat while there due to the ongoing state budget crises, but I always had some and always had in-state tuition. I believe tuition cost me about 10k total if I count stipends against it (but not money from internship). None of that happened by accident, I had to actively shape aspects of it, but it can be done.

After paying my dues (or finished being exploited for profit) at post-doc, I formed an LLC and started working as a therapist because I prefer it to assessment after having done plenty of both. Again, it’s not a guaranteed path, but I have to say, those that say you can’t make good money doing mostly therapy as a psychologist are off base. You can, but you have to be driven, learn to market, be good at what you do, and have the capacity/willingness to work an actual full time schedule. If those things are true my experience is that therapy can provide income for a psychologist comparable to or even exceeding the average psychiatrist’s earnings.

Care to qualify that statement a bit? Most psychiatrists I know earn between $250-400k. No individual therapist I know if pulling down that kind of money working alone without a number of associates working for them.

 

[WisNeuro]

Care to qualify that statement a bit? Most psychiatrists I know earn between $250-400k. No individual therapist I know if pulling down that kind of money working alone without a number of associates working for them.

Yeah, I was curious about that one as well, maybe in a major metro, cash pay, very good marketing, they could pull it down. But, you're looking at a very small percentage of providers then (<1%).

 

[Sanman]

I've thought about this quite a bit as someone from a non-privileged background nearing the end of a PhD and I'm starting to think the only reason this isn't an option in our field is because there isn't enough diversity in the positions of power to really push for this. The attitude that one can't become a researcher without sacrificing all else (and how is it really a sacrifice if privilege affords you people who take care of your needs?) in exchange for a funded program that doesn't fund nearly enough regardless of privilege/non-privileged background is just absurd. Speaking only of the self-funding the whole way, some PsyD programs seem to offer something close to what is observed in Social Work/Nursing. Some seem to be designed for students to get a licensed Master's en route (and may even require this) and then one can work in the field while completing doctoral requirements. This type of option is understandably appealing to those who have families to support, health insurance to cover, and other circumstances to consider. PhD programs could also do this (perhaps some do) and could still produce researchers, some of whom would choose the academia route. The key difference I see between the PsyD programs doing this and the PhD programs rolling their eyes at the thought is the latter is often controlled by whiteness and privilege. I have many thoughts about how to address that, but I think I have said enough.

A big issue is step-wise licensing. Most psychology masters degrees one gets along the way to a PhD are not licensed. Psychology also has wishy-washy standards compared to other professions, by this I mean you can pass all the objective tests and be released from a program because you are not getting along with mentors, faculty, etc. These are not obstacles that cannot be overcome. However, psychology is historically a privileged field and continues to be in many ways. I watch interns and post-docs graduate into jobs that often involve providing services to those that can afford to pay $200/hr out of pocket in ritzy group practices year after year. Most of those that get these jobs fit a certain profile.

 

[PsySeeker]

Care to qualify that statement a bit? Most psychiatrists I know earn between $250-400k. No individual therapist I know if pulling down that kind of money working alone without a number of associates working for them.

Hey Sanman, how would you like me to qualify it? I’m not in a high cost metro but still a major one. Most psychiatrist I know here (admittedly not too many) are making at the very low end of your range, if that. I’d also be in the low end of your range currently. Could do more (demand wise) but have to draw the line somewhere. I am sure I’m out there in the tail but I don’t think I’m that special, in that it could be done by more folks, its just not a straightforward path, and it involves more than just clinical skills, obviously. Does that answer your question?

 

[PsySeeker]

Yeah, I was curious about that one as well, maybe in a major metro, cash pay, very good marketing, they could pull it down. But, you're looking at a very small percentage of providers then (<1%).

A major city but not one of the nations top 20, but office is in the heart of it. Almost all insurance pay (in this market at least the major commercial insurers pay adequately, I think? Maybe that is different elsewhere?). I do all my own marketing, which is basically a website I made and being on some directories. I also haven’t been at it very long, but I do have a former background in business, which I think makes some of the non-psychology aspects of it come somewhat more easily (or at least I know vaguely how to begin aspects of it, lol). I also think the current tele situation has made having a busy/efficient practice more obtainable.

 

[tr]

Care to qualify that statement a bit? Most psychiatrists I know earn between $250-400k. No individual therapist I know if pulling down that kind of money working alone without a number of associates working for them.

The psychologist who works with our group has a private practice for psychotherapy in which she charges the same as our (M.D.) list price for an intake and more for a follow-up. Unless she is working 1/2 time or less, she is almost certainly making well into the quoted range. (And very certainly more than me, given my lame ass academic salary.)

 

[Sanman]

Hey Sanman, how would you like me to qualify it? I’m not in a high cost metro but still a major one. Most psychiatrist I know here (admittedly not too many) are making at the very low end of your range, if that. I’d also be in the low end of your range currently. Could do more (demand wise) but have to draw the line somewhere. I am sure I’m out there in the tail but I don’t think I’m that special, in that it could be done by more folks, its just not a straightforward path, and it involves more than just clinical skills, obviously. Does that answer your question?

Qualify with a few general details about what you mean

Are you talking $200-250k then?
Are you talking solo practice?
Gross revenue or net expenses?

It is always good to get a more accurate picture of what you mean. I understand we don't always want to share details. However, people's imaginations of vague references can runaway with them. That said, more datapoints about the marketplace are always appreciated by me as well.

 

[Sanman]

The psychologist who works with our group has a private practice for psychotherapy in which she charges the same as our (M.D.) list price for an intake and more for a follow-up. Unless she is working 1/2 time or less, she is almost certainly making well into the quoted range. (And very certainly more than me, given my lame ass academic salary.)

Does she accept insurance or are we speaking cash only? Insurance in my neck of the woods is more like $70-$150/ session for intake or 90834/7 sessions

 

[beginner2011]

A major city but not one of the nations top 20, but office is in the heart of it. Almost all insurance pay (in this market at least the major commercial insurers pay adequately, I think? Maybe that is different elsewhere?). I do all my own marketing, which is basically a website I made and being on some directories. I also haven’t been at it very long, but I do have a former background in business, which I think makes some of the non-psychology aspects of it come somewhat more easily (or at least I know vaguely how to begin aspects of it, lol). I also think the current tele situation has made having a busy/efficient practice more obtainable.

Mind sharing the per-session length and rate that you're being paid for by the insurance companies? From what I've seen insurance companies in the major metros are typically paying in the $100 per 45m to $125 per 60m psychotherapy session (and I've heard folks get push-back for routinely billing 60m).

Also, curious about the number of sessions you're doing per week?

 

[beginner2011]

Been listening to a talk, so thought I'd do a lazy-man's crunch of the numbers for median debt:income ratios by profession. It's a pretty rough estimate, since I left the debt to continue to accrue interest as though one weren't paying on the debt at all. Still interesting, I think, though. Maybe a finance person can fine tune things.

What surprised me is that for the median Master's level (orange) compared to the median PhD (yellow), the PhD hasn't caught up by year 14! It would probably be year 17 or so before things fully evened out. This is probably in part due to the fact that the loan accrual was left to continue compounding, which punishes high debt. Also, at year 14 the PsyD is less than half of the net income of the Master's level. It looks like those lines actually may not ever intersect. My take away is that net-income between PsyD and Master's level appear to be roughly the same (using medians, and some punishing of high debt as mentioned above).

Median debt by profession for table one to the right.
Median salary by profession for table two to the right (residency and staff levels).

Loan debt

1​

2​

3​

4​

5​

6​

7​

8​

9​

10​

11​

12​

13​

14​

Debt

Profession

MD

-62500​

-125000​

-187500​

-250000​

-264500​

-279841​

-296072​

-313244​

-331412​

-350634​

-370971​

-392487​

-415251​

-439336​

MD

250000​

PhD

-10714.3​

-21428.6​

-32142.9​

-42857.1​

-53571.4​

-64285.7​

-75000​

-79350​

-83952.3​

-88821.5​

-93973.2​

-99423.6​

-105190​

-111291​

PhD

75000​

PsyD

-33333.3​

-66666.7​

-100000​

-133333​

-166667​

-200000​

-211600​

-223873​

-236857​

-250595​

-265130​

-280507​

-296777​

-313990​

PsyD

200000​

Master's

-10000​

-20000​

-30000​

-31740​

-33580.9​

-35528.6​

-37589.3​

-39769.5​

-42076.1​

-44516.5​

-47098.4​

-49830.2​

-52720.3​

-55778.1​

Master's

30000​

Gross

1​

2​

3​

4​

5​

6​

7​

8​

9​

10​

11​

12​

13​

14​

Residency

Staff

Profession

MD

0​

0​

0​

0​

63400​

126800​

190200​

398200​

606200​

814200​

1022200​

1230200​

1438200​

1646200​

MD

63400​

208000​

PhD

0​

0​

0​

0​

0​

0​

0​

50000​

138000​

226000​

314000​

402000​

490000​

578000​

PhD

50000​

88000​

PsyD

0​

0​

0​

0​

0​

0​

50000​

126000​

202000​

278000​

354000​

430000​

506000​

582000​

PsyD

50000​

76000​

Master's

0​

0​

0​

50000​

108013​

166026​

224039​

282052​

340065​

398078​

456091​

514104​

572117​

630130​

Master's

50000​

58013​

Net

1​

2​

3​

4​

5​

6​

7​

8​

9​

10​

11​

12​

13​

14​

Profession

MD

-62500​

-125000​

-187500​

-250000​

-201100​

-153041​

-105872​

84956.06​

274787.9​

463566​

651229.2​

837712.9​

1022949​

1206864​

PhD

-10714.3​

-21428.6​

-32142.9​

-42857.1​

-53571.4​

-64285.7​

-75000​

-29350​

54047.7​

137178.5​

220026.8​

302576.4​

384809.8​

466708.8​

PsyD

-33333.3​

-66666.7​

-100000​

-133333​

-166667​

-200000​

-161600​

-97872.8​

-34857.4​

27404.85​

88870.33​

149492.8​

209223.4​

268010.3​

Master's

-10000​

-20000​

-30000​

18260​

74432.08​

130497.4​

186449.7​

242282.5​

297988.9​

353561.5​

408992.6​

464273.8​

519396.7​

574351.9​

 

[WisNeuro]

A major city but not one of the nations top 20, but office is in the heart of it. Almost all insurance pay (in this market at least the major commercial insurers pay adequately, I think? Maybe that is different elsewhere?). I do all my own marketing, which is basically a website I made and being on some directories. I also haven’t been at it very long, but I do have a former background in business, which I think makes some of the non-psychology aspects of it come somewhat more easily (or at least I know vaguely how to begin aspects of it, lol). I also think the current tele situation has made having a busy/efficient practice more obtainable.

You must have crazy good insurance rates in your area. Unless someone were working 60-80 hours a week, or doing a good chuck of forensic, pure therapy work isn't coming close to getting a gross of 200k+.

 

[beginner2011]

You must have crazy good insurance rates in your area. Unless someone were working 60-80 hours a week, or doing a good chuck of forensic, pure therapy work isn't coming close to getting a gross of 200k+.

That math seems off. If someone charges $150/session and does 30 sessions/week for 48 weeks/year they're grossing about $200k. A lot of psychologists providing therapy charge much more than $150/session and meet with 30pts/week.

 

[WisNeuro]

That math seems off. If someone charges $150/session and does 30 sessions/week for 48 weeks/year they're grossing about $200k. A lot of psychologists providing therapy charge much more than $150/session and meet with 30pts/week.

I thought he said he took mostly insurance. Insurances here don't pay that much for sessions.

 

[beginner2011]

I thought he said he took mostly insurance. Insurances here don't pay that much for sessions.

It looks like Manhattan is about $150 per 60m psytx session. Presumably everywhere else is lower. Also, my understanding is that insurance companies tend to audit people who routinely bill for 60m psytx, so most don't do it? Not sure how accurate that is.

 

[PsySeeker]

It looks like Manhattan is about $150 per 60m psytx session. Presumably everywhere else is lower. Also, my understanding is that insurance companies tend to audit people who routinely bill for 60m psytx, so most don't do it? Not sure how accurate that is.

Not accurate, 60 mins has been the most commonly billed code for years nationwide. Many major insurers have no problem with it, have come to view it as the standard. A few national players did or had restrictions initially, but these have largely gone away, I think one hasn’t eliminated all restrictions but has eased somewhat. Very nearly all I bill are 60 minute codes. Some clients @ 2x per week. I don’t worry about an audit because every session I bill clearly meets the criteria for the code, so an audit would only reveal that I’ve been doing all the work that I billed them for ‍♂

 

[PsySeeker]

I thought he said he took mostly insurance. Insurances here don't pay that much for sessions.

What do they majors pay for 60 mins doctoral level there? I think if you do the math you won’t find it so unlikely.

 

[PsySeeker]

You must have crazy good insurance rates in your area. Unless someone were working 60-80 hours a week, or doing a good chuck of forensic, pure therapy work isn't coming close to getting a gross of 200k+.

lol, what in the world are you talking about? This board sometimes...for someone to bill 80 hours and not come “close to getting a gross of 200” they’d be getting like $40 per 60 minute session. Medicaid pays something like 150% of that in most areas and they are typically considered the worst, often by wide margins, as far as reimbursement.

 

[beginner2011]

lol, what in the world are you talking about? This board sometimes...for someone to bill 80 hours and not come “close to getting a gross of 200” they’d be getting like $40 per 60 minute session. Medicaid pays something like 150% of that in most areas and they are typically considered the worst, often by wide margins, as far as reimbursement.

My impression is that VA and Neuropsych are generally overrepresented on this board which leads to underestimation of billing for individual psychotherapy in the community.

 

[Therapist4Chnge]

My impression is that VA and Neuropsych are generally overrepresented on this board, so providing individual psychotherapy in the community is assumed to be for the plebs.

That's a fair point....and I believe true.

I'm one of those ppl (neuropsych & forensic) & the vast majority of my income is from assessment & supervising others. I keep a small follow-up education & counseling caseload for some variety. Billing is usually 60min, which equates to $205-$215 for a 60min (CPT: 90837) follow-up session. Psych-related income isn't $250k+/yr yet, but it's doable if I worked more.

Any student reading this...this is not the average experience & every student thinks they will be an outlier. Part of the reason I left academic medicine was to maximize my earning so I can pay off my loans bc debt worries me. Once my student loans are paid off, I'm going down to 3.5 days or less bc I'd rather work smarter than harder.

 

[tr]

Does she accept insurance or are we speaking cash only? Insurance in my neck of the woods is more like $70-$150/ session for intake or 90834/7 sessions

Cash. Who takes insurance for individual psychotherapy? Nobody around here.

 

[WisNeuro]

It looks like Manhattan is about $150 per 60m psytx session. Presumably everywhere else is lower. Also, my understanding is that insurance companies tend to audit people who routinely bill for 60m psytx, so most don't do it? Not sure how accurate that is.

Some insurances will not reimburse for 60 min sessions unless you provide justification, which usually has to go through several appeals to work, if at all.

lol, what in the world are you talking about? This board sometimes...for someone to bill 80 hours and not come “close to getting a gross of 200” they’d be getting like $40 per 60 minute session. Medicaid pays something like 150% of that in most areas and they are typically considered the worst, often by wide margins, as far as reimbursement.

So let's take the usual 45 min reimbursement, which is what most people will be using, either due to time or reimbursement by insurers. CMS pays about $100 for that. Some insurers pay more, some less. So, we'll go with 100 for now. 100 a pop at 30 sessions a week, $3000. 48 weeks of that, 144k. Now, that assumes you have a full 30 slot, every week, no no-shows, cancellations, finding new pts, etc. Also, for most, 30 pts a week is going to put you above the 40 hr mark. After paying things that an employer would normally pay, you're about the same as working 30 hrs a week for s system.

Cash, definitely doable, I'm just skeptical that people are out there making 200k+ a year taking insurance doing all therapy.

 

[WisNeuro]

My impression is that VA and Neuropsych are generally overrepresented on this board which leads to underestimation of billing for individual psychotherapy in the community.

Psst, some neuropsychologists also have very extensive therapy training and still do it. Also I serve on our state's payor committee, I am intimately familiar with billing for all psychological services, as well as who generally doesn't pay for what, and who pays much less than CMS.

 

[WisNeuro]

I guess we can follow up with the 60 min code here, as unlikely as it would be for someone fully billing that, 127. 127 at 30 a week is 3810, 48 weeks of that is 182. Once again, assuming full slots all round, cancellations, no shows, etc. We're still not in psychiatry income territory.

 

[Sanman]

Cash. Who takes insurance for individual psychotherapy? Nobody around here.

I used to...

 

[WisNeuro]

I used to...

Get back in your VA hidey hole!

 

[WisNeuro]

Speak of the devil, BCBS literally just sent out e-mails to many of our state members auditing their use of 90837 for the past year as they consider them "extended" visits. Our next two largest insurers pay the same for 90837 as they do for 90834.

 

[AcronymAllergy]

I'm now curious how often people nationwide use 90837 vs. 90834. I'm sure CMS has it on their website, but my search skills (and, currently, time) are lacking.

I'd always heard 90837, when used frequently, was more likely to result in an audit. I don't do much therapy, and don't do any outside VA, so I have no idea as to its truthfulness. I imagine it may vary by insurer, area, and possibly setting (e.g,. private practice vs. hospital outpatient).

The good news is there doesn't seem to be a shortage of work in most areas. And increasing telehealth utilization rates may help practices RE: no-shows (e.g., have a list of pts you can contact for a telehealth session if your scheduled patient doesn't show).

 

[WisNeuro]

I'm now curious how often people nationwide use 90837 vs. 90834. I'm sure CMS has it on their website, but my search skills (and, currently, time) are lacking.

I'd always heard 90837, when used frequently, was more likely to result in an audit. I don't do much therapy, and don't do any outside VA, so I have no idea as to its truthfulness. I imagine it may vary by insurer, area, and possibly setting (e.g,. private practice vs. hospital outpatient).

The good news is there doesn't seem to be a shortage of work in most areas. And increasing telehealth utilization rates may help practices RE: no-shows (e.g., have a list of pts you can contact for a telehealth session if your scheduled patient doesn't show).

We work with other state associations, the issuer of insurers either auditing, not covering, or paying the same for 45 and 60 is a mostly national issue. Heck, do a google search and you'll see a good deal of this pop up. One of the many reasons why "parity" is a joke.

As for telehealth, also a mixed bag, we're currently fighting with multiple insurers who reimburse lower, or who are proposing going back to not reimbursing phone and such. It's a constant lobbying and legislative struggle.

 

[Sanman]

Get back in your VA hidey hole!

Fine, but only because I saw my shadow.

 

[AcronymAllergy]

We work with other state associations, the issuer of insurers either auditing, not covering, or paying the same for 45 and 60 is a mostly national issue. Heck, do a google search and you'll see a good deal of this pop up. One of the many reasons why "parity" is a joke.

As for telehealth, also a mixed bag, we're currently fighting with multiple insurers who reimburse lower, or who are proposing going back to not reimbursing phone and such. It's a constant lobbying and legislative struggle.

Disappointing, but not surprising. I think the telehealth fight may be winnable if pts continue to request it, but probably not for continued payment of face-to-face codes with telephone.

 

[Sanman]

I'm now curious how often people nationwide use 90837 vs. 90834. I'm sure CMS has it on their website, but my search skills (and, currently, time) are lacking.

I'd always heard 90837, when used frequently, was more likely to result in an audit. I don't do much therapy, and don't do any outside VA, so I have no idea as to its truthfulness. I imagine it may vary by insurer, area, and possibly setting (e.g,. private practice vs. hospital outpatient).

The good news is there doesn't seem to be a shortage of work in most areas. And increasing telehealth utilization rates may help practices RE: no-shows (e.g., have a list of pts you can contact for a telehealth session if your scheduled patient doesn't show).

There are CMS numbers on this. People were receiving threat letters from companies on behalf of CMS stating that they were billing more sessions, 90837 codes, etc to CMS than average 1-2 years ago. It was a major discussion on the gero listservs.

 

[WisNeuro]

Disappointing, but not surprising. I think the telehealth fight may be winnable if pts continue to request it, but probably not for continued payment of face-to-face codes with telephone.

Phone will be an uphill battle. As for the video virtual, many insurers want to axe it as soon as the governors emergency powers are neutralized. That's the one we're really pushing hard as an org to make permanent.

 

[Sanman]

We work with other state associations, the issuer of insurers either auditing, not covering, or paying the same for 45 and 60 is a mostly national issue. Heck, do a google search and you'll see a good deal of this pop up. One of the many reasons why "parity" is a joke.

This was my experience as well. United Healthcare audits of services related to 90837 use and any services on a patient with any neurocog disorder was one reason I ran into my VA hidey hole in the first place. God, I don't miss that. I used to get 20+ messages per day about that when I was on call.