How We Get Paid: Part 1

On therapy, fee-for-service, and the hidden costs of clinical work

Part 1: When the Work Doesn’t Fit the Structure

It’s usually a small moment.

Not a crisis. Not a breaking point. Just a pause—often at the end of the day—when you notice how much translating you’ve done.

You think about the session that went long because it needed to.
The client who finally said the thing they’ve been circling for months.
The work that mattered—the kind that doesn’t fit neatly anywhere.

Then you open your notes.

The clinical work has to be described differently now. It becomes boxy.
The diagnosis sort of fits—and it’s necessary because your client needs insurance to pay.
The way you write gestures at what happened without actually naming it.

You tell yourself this is just how it works.

Most of us do. We learn early to focus on how to practice—techniques, ethics, modalities—not on the structures that shape the work itself. When something feels hard, we assume it’s personal: we need better boundaries, better systems, more resilience.

But at some point, a quieter question emerges:

Why does this feel so hard?

Not the emotional hard—that part makes sense, and we are here for that. We work with grief, trauma, loss, and longing. No one expects that to be easy.

It’s the structural hard that’s harder to explain.

Why does the work that feels most healing take the most energy to justify?
Why does presence count for less than productivity?
Why does so much of what matters become invisible once it’s time to get paid?

Most clinicians never receive training in the history or economics of how this work is organized. We inherit a way of practicing that feels normal because it’s familiar—because it’s what everyone does—even when it quietly undermines the very care we’re trying to provide.

This series is an attempt to make that inheritance visible.

Over three parts, I want to explore why we practice the way we do, how a fee-for-service medical model came to govern relational care, and what the impact of that model has been on clinicians, clients, and the work itself.

Along the way, I’ll argue that much of what we call burnout isn’t a personal failing or a lack of resilience, but the predictable consequence of practicing ethically constrained, relational work inside structures that were never designed for it.

Naming that history doesn’t fix the problem.

But it does change how we understand ourselves inside it—and what kinds of responses actually make sense.

When the Costs Accumulate

Because they do.

Day after day, year after year, you show up and do work that matters—real therapeutic work that heals—and then translate it into language that denies what actually happened.

Relationship becomes procedure.
Healing becomes billable units.

Each time, you shift to meet the system, just a little.

That accumulation isn’t simply burnout.

It’s moral injury.

What Moral Injury Actually Is

Moral injury isn’t about being tired.

It’s about shape-shifting.
And betrayal.

The term comes from research with combat veterans. It describes what happens when someone is required to participate in, witness, or fail to prevent actions that violate their deeply held moral beliefs—under conditions where they lack the power or authority to intervene.

In 2019, physicians Wendy Dean and Simon Talbot brought this framework into healthcare, arguing that what we’ve been calling “burnout” is more accurately understood as moral injury.

The distinction matters.

Burnout frames the problem as individual failure to cope.
The solution is individual: better boundaries, more resilience, improved self-care.

Moral injury frames the problem as structural betrayal.
It names what happens when systems prevent people from practicing according to their ethics.

With burnout, the problem is you.
With moral injury, the problem is the conditions you’re required to work within.

For clinicians, those conditions often look like this:

• You are required to diagnose clients in order to get paid, even when you know the diagnosis doesn’t accurately name what’s happening.

• You are paid by volume, not by depth or relational presence.

• You are asked to translate nonlinear, developmental, relational healing into procedural language.

• You document for the system—and to protect yourself.

Many of us have asked some version of the question: Do I have to bend my clinical knowing in order to be paid for it?

For a long time, I understood my role as acting as a bridge—translating my work so that clients could access care in a system that otherwise wouldn’t serve them. What I didn’t have, for much of my twenty-five years of practice, was a way to understand the cumulative impact of that translation on me.

I began to see it more clearly only as I divested, slowly and intentionally, from this model.

You didn’t design these conditions.
You can’t easily refuse them without risking your livelihood or abandoning clients.

That lack of refusal power is what turns strain into injury.

What This Also Costs Us

There’s another cost to all of this that we talk about even less.

Over time, these conditions don’t just exhaust clinicians—they erode our sense of agency as people with the right to shape and evolve this field.

Innovation requires certain conditions.
It asks for creativity, vulnerability, imagination, trust, and time.
It requires room to experiment, to fail, to think aloud, to follow what’s emerging rather than what’s already been sanctioned.

But the dynamics this series explores quietly eat away at those conditions.

When your work is constantly under surveillance, creativity narrows.
When legitimacy is externally defined, vulnerability becomes risky.
When you’re required to justify your care in language that misrepresents it, trust—both in yourself and in the field—erodes.

Over time, clinicians stop asking What might be possible?
They start asking What will be approved?

That shift has consequences.

It concentrates authority at the top of the hierarchy and pushes innovation to the margins, where it often emerges without resources, protection, or recognition. The people closest to the work—the ones adapting care to real lives and real conditions—are rarely positioned as authors of the field’s future.

This is how a profession loses its imagination.

Not all at once.
But slowly, through constraint.

A Double Bind I Witness—and Participate In

I want to be clear about where I’m speaking from.

I’m a white therapist. I don’t experience racialized oppression in my body. I do participate in systems that are built on it. Part of my responsibility is to name how those systems function—not to claim experiences that aren’t mine, but to refuse the fiction that our work is neutral.

Here’s a double bind I see clinicians navigate constantly.

Therapists sit with clients whose distress is a rational response to their environments—chronic racism, sexism, precarity, exclusion, and the cumulative strain of having to adapt in order to survive. Nervous systems stay on high alert not because something is wrong with them, but because the world requires it.

This is not disorder.
This is adaptation.

And yet, to bill, a diagnosis is required.

So clinicians are asked to locate the problem inside the individual:
to name anxiety where there is vigilance,
to name adjustment where there is harm,
to translate structural violence into personal pathology.

Most therapists know this doesn’t tell the truth.

That gap—between what you know to be true and what you are required to say you’re doing—is moral injury.

For therapists of color, that injury is compounded by history and lived experience. For white therapists like me, it often shows up as complicity: participating in a system we know is misnaming harm in order to keep care moving.

Different positions.
Same machinery.

A Way Forward

If you’re recognizing yourself here, it’s worth pausing.

Not to fix anything.
Not to figure out what to do next.

Just to notice what shifts when the problem is named accurately.

When the strain you’ve been carrying is understood not as personal weakness, but as the predictable result of practicing relational, ethical work inside structures that weren’t designed for it, something loosens. The quiet self-blame softens. The endless search for better coping strategies loses its urgency.

This doesn’t mean the work suddenly becomes easy.

It does mean you’re no longer asking the wrong questions.

Instead of What’s wrong with me?
You can begin to ask: What am I practicing inside of?

That question opens the door to history.

In Part 2, we’ll step back and look at how psychotherapy came to be organized the way it is—how a fee-for-service medical model, imagined for a very different kind of work, came to govern relational care and shape what counts as legitimate practice.

Understanding that history won’t fix the system.

But it will change how we locate the problem—and what kinds of responses actually make sense from here.