THE COUCH. Your chair. The artwork in your office. Your billing and cancellation policy. Whether you start and stop on time. Whether you text with patients outside of sessions or have a social media account.
All of these are aspects of the psychotherapy frame—the structure that holds the work in view and gives it coherence. Therapists devote time and attention to creating and maintaining the frame. It's more than personal preference or lessons gleaned from graduate school; the frame is essential infrastructure and carries tremendous clinical value. Having a regular cadence of therapy appointments helps show patients what reliability in a relationship feels like and offers containment for their emotions and anxieties. The office layout and design convey therapists' values around safety and intimacy and authority. How a therapist handles financial issues such as billing, payment methods, fee negotiations, and insurance speaks to issues of value, worth, reciprocity, power, and even shame and entitlement. Therapists' assurances about how they protect confidential clinical material and handle documentation offer both actual and symbolic safety.
These decisions are not arbitrary. They reflect training, experience, ethical responsibility, and ongoing assessment. Therapists know that a solid and dependable frame is critical to creating an environment in which patients can build trust, take emotional risks, think expansively, and allow psychic life to unfold with less fear.
Unfortunately, new trends in the mental healthcare landscape represent increasing threats to the frame, and thus
to the viability and effectiveness of psychotherapy. In this essay I will focus on Practice Management Companies (PMCs) like Headway, Alma, Rula, Sondermind, and Grow Therapy, which offer services to help therapists “run their practices.” Their value proposition is appealing to therapists who want to focus on providing therapy instead of insurance sign-up (credentialing), insurance billing, and marketing. Ironically, despite the benefits they advertise and their claims to give back time and control to therapists, these companies and their policies are intruding in overt and subtler ways on therapists' capacity to manage their practices and uphold the psychotherapy frame.
Before we look closely at what PMCs do, here is why the psychotherapy frame matters at the deepest clinical level. The frame is an active, meaning-laden clinical intervention where every decision communicates values, shapes transference and countertransference, and structures the patient's experience of care, power, and safety. It is integral to whether psychotherapy can work at all. When the frame is unstable or repeatedly disrupted, therapy does not merely become less convenient or optimal—it becomes qualitatively different and often less effective. Clinicians' capacity to ensure the frame is challenged when third-parties intervene. For example, when insurers impose limits on frequency, duration, or documentation, they are not simply managing cost—they are reshaping treatment and potentially undermining its effectiveness. Clinicians may be placed in ethically compromised positions, and must find ways to reconcile their clinical values and professional obligations with these external demands.
Enter PMCs. While there have long been billers, website developers, and marketers for hire, PMCs combine all of these services in one place. These are often the tasks that therapists are least interested in and least prepared to do, leading tens of thousands of therapists to sign up with a PMC. The PMC value proposition couldn't be more appealing: We'll do the boring admin tasks for you. We'll also pay you quickly and regularly—no more waiting for months for insurance reimbursements—and we'll pay you a higher rate than you could get on your own from insurers. Some PMCs even offer these services to therapists for “free,” meaning no overt costs, although, as we'll see, there are hidden costs and clinical consequences.
PSYCHOTHERAPY CANNOT BE SEPARATED FROM THE CONDITIONS UNDER WHICH IT OCCURS.
The PMCs operate as “mega group practices,” where therapists are 1099 independent contractors to the platform. This arrangement is similar to a rideshare platform like Uber or Lyft, where drivers are technically self-employed but are beholden in important ways to the structure and incentives of the platform. This type of employment classification and business relationship challenges the frame directly and indirectly, raising ethical and legal questions. Who owns the patient data and records? What happens if a therapist wants to leave the group? Who gets to make decisions that impact client care?
These mega group practices also offer few of the benefits of a traditional group practice. There is no supportive network of colleagues, no office, and no health insurance plan. Therapists work for the platform—without the legal rights of an employee—as opposed to the platform working for them.
To learn more and hear directly from therapists, Psychotherapy Action Network (PsiAN), where I am board chair and cofounder, surveyed nearly 700 mental health professionals about their experiences managing the business and administrative aspects of practice, including the use of practice management companies. The findings offer a rare window into the impacts of these systems on core conditions of care.
Nearly all therapists surveyed rated client privacy as extremely important. Yet among those clinicians using PMCs, the majority (81%) reported concern that these platforms do not adequately protect patient information. Therapists expressed anxiety about data tracking, third-party data sharing, and the use of clinical material for purposes unrelated to care, such as training artificial intelligence systems. Headway, an online practice management platform, is the subject of a class action lawsuit brought by users alleging that it allowed Google's tracking technology to collect sensitive mental health data without adequate consent. While this case is ongoing, and Headway denies the accusation, the allegations illustrate broader concerns about data privacy in digital mental health platforms.
Confidentiality is not merely a legal obligation; it is a core condition that allows patients to speak freely without fear. When therapists or patients believe that clinical material may be tracked, monetized, or repurposed, the symbolic safety of the frame is compromised. The PMCs assert that they comply formally with HIPAA guidelines, but their data tracking and sharing practices which convert patients' private thoughts and feelings into a commercial asset undercut this assertion. The erosion of privacy weakens the frame and undermines the effectiveness of therapy, while enriching the PMCs and their owners.
Clinicians using PMCs reported concerns about session limits, changing reimbursement terms, and new value-based payment models (where clinicians are paid a capitated lump-sum based on variables such as scores on symptom measurement tools or diagnoses, as opposed to payment for the time they spend providing care).
These practices destabilize treatment continuity, stability, and consistency. This instability may contribute to patient dropout and premature termination, particularly for patients with trauma histories, mood disorders, or relational difficulties. It also changes the meaning, focus, and potential depth of psychotherapy. When care is repeatedly threatened with oversight or interruption, psychotherapy can shift away from deeper, exploratory work focusing on entrenched beliefs or repeating emotional patterns and toward crisis management. It can even redirect clinicians' attention to documenting and tracking symptom acuity rather than holding space and time to process patients' experiences. These shifts can create their own harm, potentially reinforcing some patients' expectations of abandonment.
In addition, frame disruptions around continuity of care disproportionately affect lower-income patients, publicly insured patients, and those with complex or relational trauma—precisely the populations most likely to require clinical stability, reliability, and depth of care.
This study revealed widespread lack of transparency about financial terms, with many therapists not understanding the basics of their compensation or only learning these details after they joined. Of those therapists using PMCs, 84 percent stated they were unaware of how the reimbursements from insurers were split between them and the PMC. These fee-splitting calculations are common knowledge at traditional group practices.
In addition, one of the most enticing aspects of PMCs—the promise that therapists will be paid more—remains largely unfulfilled. Therapists are not typically interested in being paid more out of greed, but rather out of frustration with insurers' well-documented practices that discriminate against mental health care; therapists are paid about 20 percent less than comparable clinicians in the medical/surgical field. These low reimbursement rates, combined with excessive administrative demands, have led many therapists to make the rational choice not to join insurance networks. The results are fewer options for individuals to use their insurance plans to cover psychotherapy, higher costs if they find a therapist out-of-network, and drastically reduced access to therapy for the public.
PMCs advertise that therapists will earn more working with them than independently, because PMCs can use the thousands of therapists in the mega-group to negotiate better rates with insurers. However, PsiAN's research revealed that only half of therapists actually earned more, with half earning the same or less. Many therapists viewed this as just one of the bait-and-switch tactics they experienced after signing up with a PMC.
In psychotherapy, money is not only a transaction but a symbolic signal of value, responsibility, expectations, and mutual commitment. Nontransparent fee structures and shifting payment terms distort this economic frame, introducing confusion and undermining therapists' capacity to hold stable boundaries around time, frequency, and care. This is also a clear failure of informed consent for therapists and indirectly for patients.
Clinical autonomy is being eroded by PMCs' direct contact with patients. When therapists enroll with a PMC, their patients do, too. The PMCs collect patients' copays and are increasingly collecting additional information from them as well. For example, several PMCs have started to send symptom checklists directly to patients without asking or informing therapists, let alone obtaining their consent. This direct intrusion of PMCs into the therapist-patient
relationship is not only frame-breaking but threatening to privacy, ethics, and the clinician's authority in taking care of the patient. The trust and authority earned by the therapist, granted by the patient, is at risk, paving the way for enactments around control, if not premature termination, of the therapy.
There are additional questions about the use and meaning of self-report symptom checklists, including how and whether they align with the goals of the treatment. In previous research studies by Psychotherapy Action Network, the majority of individuals stated that their goals as a patient were to get to the root of their issues and increase self-awareness—goals that are deeper and broader than assessing discrete levels of symptomatology.
While therapists understand these companies are in business for themselves, they don't know a lot about how these companies make money or who profits from them. The PMCs are not transparent about this, and many therapists don't realize these companies are owned by private equity firms, venture capital investors, technology firms, and even insurance companies. As reported in our survey, therapists' main stressor was dealing with insurers; ironically, if therapists join a PMC, they then become a contractor to a company owned by insurers.
Indeed, a striking finding of the PsiAN study is clinicians' strong aversion to insurer ownership of PMCs. While most respondents (70%) were unaware of ownership structures, the overwhelming majority (85%) reported that they would not participate in platforms owned by insurance companies. This reflects widespread worries about insurers' influence and concerns that clinical decisions are increasingly shaped by financial incentives external to the therapeutic dyad.
As this research shows, PMCs are having an outsize impact on the frame, provision of care, therapeutic relationship, and potential for psychotherapy to last long enough to provide its life-saving, life-transforming benefits. Without being more clear-eyed about these new digital middlemen, troublesome outcomes such as higher dropout rates, shorter and less effective courses of care, and increased clinician burnout will lead to the impression that psychotherapy just doesn't work, especially for complex or chronic problems. Poor outcomes will be blamed on noncompliant or resistant patients or inefficient or ineffective clinicians.
The popularity of PMCs is understandable. In the research study, therapists reported that their top concerns revolved around the administrative burden of dealing with insurers, the low reimbursement rates, and arbitrary limits on (or outright denials of) coverage. Financial stability was another concern: Forty-three percent of respondents lacked paid time off, 40 percent struggled to earn sufficient income, and 35 percent lacked access to affordable benefits like health insurance and retirement plans. Therapists reported significant stress related to the demands of running a private practice as a small business. Early-career clinicians expressed the need for more structured supervision, mentorship, and advanced training, as well as frustration about being able to afford it. For those later in their careers, professional burnout was prominent. Juggling practice administration, documentation, supervision, and continuing education, as well as the emotional intensity of providing psychotherapy, contributed to burnout and fatigue.
But if we are to improve access, outcomes, and clinician sustainability, attention must shift from solely what interventions are delivered to how therapy is structured. Psychotherapy cannot be separated from the conditions under which it occurs. At a minimum, this means protecting the frame to ensure psychotherapy has a chance to be effective. Frequency and intensity of sessions must be based on clinical need. Confidentiality must be defended, and not limited to policies that meet minimal compliance. Transparency of financial matters, ownership, and payment structures is necessary. We do not need more middlemen and more administrators. We need them to get out of the way so we can safeguard clinicians' authority over treatment decisions.
Insurers have shown—through PMCs—that they can change their many discriminatory practices. PMCs offer credentialing within 60 days, not six months as is often the case; reimbursement rates may be higher; payments to therapists can occur on a regular basis. These “revolutionary features” should be offered to all therapists immediately, not only those who join a PMC.
Clinicians must educate themselves about these new companies and new trends emerging in the field. They need to reassert their authority as the party responsible for and in charge of the care provided. They need to view business decisions as clinical ones and recognize the impacts and consequences of systemic intrusions into the frame. Protecting the psychotherapy frame is not about preserving tradition or privileging one orientation over another. It is about safeguarding the conditions that allow therapeutic relationships—of any modality—to do what they are meant to do: help people heal, grow, and change.
Linda Michaels, PsyD, MBA, is a psychologist in Chicago. She is chair and cofounder of the Psychotherapy Action Network (PsiAN), consulting editor of Psychoanalytic Inquiry, clinical associate faculty at the Chicago Center for Psychoanalysis, and fellow of the Lauder Institute Global MBA program.
First published online March 2026