Connecting the Dots: The Price of Fragmentation in Mental Health Care

The Introduction of a Five-Part Series

Introduction

I want to tell you something that took me a long time to say out loud: I think we did this to ourselves. While I am writing primarily from my perspective as a counselor, it is important to acknowledge that this systemic crisis is not unique to my specific corner of the field. Every mental health discipline, whether psychology, social work, or marriage and family therapy, has contributed to the current state of affairs through its own internal divisions and organizational choices. However, I am focusing this critique on the counseling profession because it is the world I know most intimately and where I have lived the consequences of these decisions for over two decades.

We did not get here entirely on our own. We had significant help from insurance companies, private equity investors, and a broader healthcare system that has never particularly valued the depth of mental health work. But when I look at where masters-level clinicians stand right now, I see a workforce that is underpaid, administratively overwhelmed, and increasingly dependent on corporate platforms that profit from our labor. We are working in a system that still does not fully recognize our expertise, and I keep coming back to the same uncomfortable conclusion: a significant part of how we reached this point was our own doing. More precisely, it was the doing of the professional organizations and accreditation bodies that claimed to speak for us while they were actually pursuing their own institutional survival.

I have been a Licensed Mental Health Counselor for a long time. I did not attend a CACREP accredited program because, at the time, I didn’t even know what CACREP was. My masters degree is in Clinical Psychology with a Counseling Specialization. I trained at The Chicago School of Professional Psychology, where my professors were clinical psychologists who not once made me feel inferior or ill equipped to become a masters level therapist. They rooted our training in psychological theory (I’ll be coming back to this point later in the series) and taught us how to think before they taught us how to intervene.

Over the years, I have practiced in numerous settings from crisis outreach to school based mental health to residential and eventually became a clinical director and group practice owner. I am also a nationally credentialed approved clinical supervisor. I have watched this field evolve from close range, and my frustration is rooted in that experience. I spent two years in a PhD program in Counselor Education and Supervision because I wanted to help shape the next generation of clinicians. I eventually left that program because within a CACREP accredited program, I felt that my nearly 20 years in the field was seen as an obstacle and not an asset in a machinery of professional identity formation rather than critical thinking and advancing the field, which was something I could no longer align myself with. This experience made me reflect on all of the systems that impact our work, including the ones we’ve created and it left me frustrated in a way that I think a lot of you share but not everyone is saying clearly.

This series is my attempt to say it clearly.

Over five parts, I’m going to make a specific argument: that the mental health counseling profession spent decades organizing itself around professional identity rather than around the material welfare of its clinicians and the clinical depth of its training, and that this failure created the exact conditions that venture capital and insurance companies needed to move in, insert themselves between clinicians and clients, and extract value from a workforce too fragmented to effectively resist.

Part One looks at the accreditation and identity politics that have shaped, and in important ways, distorted the counseling profession’s sense of itself. It traces the profession’s origins in vocational guidance, examines how CACREP consolidated power, and asks an uncomfortable question: if the counseling profession borrowed every theory it uses from psychology and adjacent fields, what exactly is the distinct identity it has been so fiercely protecting and how does this stance provide the scaffolding needed to advance our profession when it silos us from our colleagues who are facing the same challenges we are?

Part Two examines the material cost of that fragmentation: the decades of Medicare exclusion, the 75% reimbursement rate baked into statute with no clinical basis, the government-sanctioned price-fixing mechanism that set the rates our entire market benchmarks against and what 42 years of organized dietitian advocacy tells us about what we could have built instead.

Part Three gets into the legal frameworks that were supposed to protect us and largely don’t. MHPAEA prohibits unequal financial treatment but explicitly does not regulate provider reimbursement rates. ERISA exempts 64% of employer-sponsored coverage from state insurance law entirely. The laws look like protection from a distance and function as anything but up close.

Part Four examines what happened inside the training programs while all of this was unfolding outside them, how identity politics degraded the philosophical and theoretical depth of how we prepare clinicians for the work, and what that costs clients.

Part Five brings it to the present moment: the behavioral health carve-outs that were engineered in the 1980s to cut costs, the VC-backed platforms that have moved into the vacuum the profession created, the insurance companies investing in the very platforms managing their clinician networks, and the payment processing layer extracting fees from reimbursements clinicians are contractually owed.

This is not a series about hating the field. I am in this field because I believe in it. I believe in the work. I believe in the clinicians doing it. What I don’t believe in anymore is staying quiet about the systems including our own professional systems that are making that work harder, less sustainable, and less clinically excellent than it should be.

The goal of Therapists Unchained has always been to say the thing out loud. This series is that.