There is a broad awareness that we are in the throes of a mental health crisis in this country. Open discussions of increases in depression, anxiety and suicide attempts are common among news outlets and social circles, while the real impact is being felt in the homes of those suffering every day. When discussing the mental health crisis, the typical focus is the increasing incidence of mood disorders and suicidality. What has been consistently and systemically overlooked is our lack of providers. This article is going to delve into the financial reality that contributes to our mental health crisis.
When someone needs a counselor, the counselor is “worth their weight in gold.” Why is it then that counselors may be the most underpaid, advanced-degree medical professionals in this country? Recently, I was talking to a couple of peers who are also professional counselors, and one stated that a new professional they know was just offered a job starting at $29,000. The other shook their head, looked down and then back up in frustration, and stated, “Last week when I was driving through Michigan, a fast-food place was offering $1,000 sign-on bonuses and $18 an hour.” We will get into the whys later, but this is the disparity that is also a reality in our field.
By the numbers
Let’s start by looking at how much counselors actually make. According to the CareerExplorer website, the average salary of a mental health counselor in the United States is around $35,642 per year. The bottom 20% are placed at $29,800, whereas the top 20% are placed at $57,100. CareerExplorer also offers breakdowns of the average mental health counselor salary by state, with Tennessee coming in at a low of $31,000 per year and Alaska being at the top of the chart with an average salary of $63,900. My current home state of Ohio shows an average salary of $44,100 for mental health counselors, with the bottom 20% at $31,800 and the top 20% at $65,100.
CareerExplorer appears to offer the most accurate of the pay ranges I found in my search because it focuses on master’s-level mental health counselors providing direct care services in a variety of settings. Several other resources show salary ranges of $33,000-$75,000, with some going as high as $100,000, but most of these blur the lines by including Ph.D.-level psychologists, testing, and a number of services that significantly skew the average salary.
As professional counselors, we know what it takes to enter this field, but the general public does not. Educational and experiential requirements can vary somewhat state to state, but for many of us, it starts with a 60-credit-hour master’s degree, which also typically includes an unpaid 100-hour practicum and a 600-hour internship. State boards, the National Counselor Examination, background checks and ongoing supervision get you in the door. Then you must continue with supervised hours, continuing education, training in models and additional hurdles. These are not bad things; they build our body of knowledge, increase standards for the field and lend us credibility. They also come at a cost of both time and money, which are valuable commodities in our field.
With an understanding of the rigor and length of the educational requirements of clinical counselors, and the additional information of what the typical salary range is, how does this compare to national averages? According to the U.S. Bureau of Labor and Statistics (2021), the average salary for someone in the U.S. with a master’s degree is $77,844. The average salary for someone with a bachelor’s degree is $64,896. These are not starting salaries, but average salaries, just as the average salary for a master’s-level counselor in Ohio is $44,100 and nationally is $35,642. If you reference Northeastern University’s Education Pays Chart, you are able to see where counselors fall.
Implications
Now that we have established that counselors are significantly underpaid, it is important to explore likely implications.
The first implication is burnout, which affects the field twofold in that it shortens careers significantly and impairs providers who continue to actively work. The average counselor has a productive life span of 10 years before burnout is almost inevitable.This does not account for increased stress in our society due to the COVID-19 pandemic, politics or a volatile social environment.
Why does average salary impact burnout? Because the lower the income, the more stress is created. According to Matthew Killingsworth (2021), drawing on 1,725,994 experience-sampling reports from 33,391 employed U.S. adults, the results demonstrate that both experienced and evaluative well-being increased with income. Factors include being able to pay student loans, afford housing and not worry about how a master’s-level medical professional will pay for a child’s sporting or extracurricular activities. It also extends professionally, in that increased reimbursement allows for lower caseloads, increased preparation time, and more funding for training and professional development.
This creates a natural transition to the second implication — the link between better care for the professionals and improved patient care. If we are supporting our professionals through decreasing caseloads to more manageable levels, increasing purposeful training and promoting more professional development, we are going to see improvements in patient care. Research demonstrates that when using researched-based interventions, we see significant increases in client care, but also accountability in the profession. Effective care means improved outcomes and reduced durations of service, which not only means happier people, but also healthier and more productive people.
A third implication is the impact on recruiting and retaining quality professionals in our field. Unfortunately, in the past decade we have witnessed a tremendous number of counselors shifting to other professions and fields. Some have moved to aligned fields, such as school counseling or education, and many have moved to much different venues, including real estate, IT and software development.
As mentioned previously, we are often experiencing a productive span of 10 years after an education that required seven years to achieve. This is, by any standard, a very poor return on investment. These moves are frequently the result of burnout and the desire to improve their financial situation.
In a similar vein, it can be difficult to attract individuals to the field when it is widely known how stressful and underpaid the profession is. This is even more complicated, as in the past two years we have seen an unprecedented spike in need, with such limited resources and an extended training period.
If the field is to continue to recruit the best and brightest, it also has to offer them competitive wages. If the goal is to increase our recruitment, that point is even more important. It goes beyond simple difficulty and pushes into societal values and ethics when highly educated counselors are starting at significantly lower salaries than individuals with entry-level positions in business.
As we consider education, recruitment and wages, it is also important to examine this topic in terms of social justice. Counseling is a field that has disproportionately high numbers of women and marginalized populations, while also demonstrating disproportionately low wages. Nothing has been found in the literature to demonstrate a causal relationship, but the correlation is difficult to deny. With a workforce that, according to the U.S. Bureau of Labor and Statistics (2021), is 73.3% female (compared to the U.S. average of 46.8%) and nearly 40% nonwhite (compared to U.S. averages of 22%), this is a field composed largely of minoritized workforce populations.
The fact that counselors are, by nature, helpers and are often willing to give freely of their time does not mean that they should be treated unfairly as a labor force. This lends to revisiting the education required and a comparison with other professions.
The fact that a counselor has completed a 60-credit-hour master’s program is significant, as most master’s programs require 30 credit hours, with “more complex and in-depth programs” increasing this to as much as 40 credits. According to U.S. News & World Report (2021), the average master’s program requires 32 to 36 credit hours. It is also important to note that most programs do not have an intensive internship requirement like that of counselor education.
If we look at similar practitioners, such as nurse practitioners, a master’s in nursing is a minimum of 36 credits, and a doctorate in nursing is an additional 36. Another line of work that could be considered similar would be a physician assistant. To become a physician assistant, a master’s degree is required, which is a standard three-year program, as well as 2,000 clinical hours. As these three have the most similarities regarding education and clinical setting and resulting in jobs that include diagnosing and treating medical disorders, these are my base of comparison.
As we have already established, the average counselor in the United States makes $35,642 per year, while the average annual salary for nurse practitioner is $114,510 and the average annual salary for physician assistant is $115,390. It seems quite reasonable for the counseling field to be funded in a manner that allows for paid internships, starting wages in the $75,000 range, and average earnings to be in the range of a nurse practitioner or a physician assistant.
The solution is simple: to align the reimbursement rate for counselors to a rate commensurate with that of similarly educated professionals in the field of medicine, which would also realign income to that of similarly educated professionals in all fields. Well-run mental health offices carry much of the same overhead as other medical and professional offices, including clean and inviting environments, support staff to assist with clients and administrative needs, commercial-grade furniture to handle heavy use, and solid construction that also provides sound deadening for the space. Offices need technology, which continues to expand with electronic health records and testing, and the electronic health record systems themselves, along with constant upgrades and IT support.
The idea of moving the average counselor salary from $35,642 to the wages discussed above would seem to require reimbursement to triple, but it would not. If we were to share the burden, both by focusing on increased efficiency and increasing reimbursement, these changes could be implemented with a reimbursement increase of approximately 80% as opposed to an expected 300%. This would provide the opportunity for clinicians to decrease caseloads slightly, provide better care and make a wage commensurate with their work, education and ongoing educational requirements.
Ask yourself this question: When you are seeking help from a counselor for your child or significant other who is suicidal, do you want someone who is on the top of their game, or someone who is struggling to make ends meet and may be nearly as stressed out as those they are serving?
ashadhodhomei/Shutterstock.com
****
Derek J. Lee is the founder and CEO of Perrysburg Counseling Services and The Hope Institute. In addition to clinical work and administrative roles, Derek is finishing his Ph.D. in counselor education at Ohio State University and teaches in the Department of Clinical Counseling and Mental Health for Texas Tech University Health Science Campus.
****
Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.
Counselor/therapists need to be paid more. Spending majority of your days on other peoples issues and then coming home knowing you can barely scrape by financially is not going to help this profession grow. There has to be more of a “fair shake” in this industry. Higher Wages and more starting PTO!
Agree with Matt totally! We need higher wages, better work conditions, way more PTO, tools for self care, more respect from other professions…I could go on. The reality is that unless something drastically changes in the way counselors are treated/perceived/reimbursed, an extreme shortage of these valuable professionals is inevitable.
The current model we have for community health therapists is broken. I am in private practice and I can make a livable wage, but those who work in an agency, for example) make little money and see too many clients for the work to be sustainable for their own mental and physical health. Also, the severity and complexity of the clients’ mental illness is much greater. This leads to burnout and turnover, which then affects the clients due to a disruption in case, etc. While we have seen parity in being able to see clients without limits, we have not seen parity in pay. What can we do an individual therapists? I would be interested in hearing what others have to say. Clearly speaking about it is a great step. Getting in contact our legislators is another good step.
I agree wholeheartedly with Wendy. What can we do as individual therapists? I’ve read about this for so long and have complained and even tried to get rate increases, which often results in removing myself from insurance networks. I would also suggest mentoring soon-to-be therapists in graduate schools about insurance providers and how low fees hurt our field. The established providers may be limited in what they can do with the insurance networks, but we could help by starting with the graduate students, not supervision but mentoring.
So far, you are all right. We already have a shortage of professionals in our industry and cannot train enough counselors fast enough to make any real headway. Wendy and E. Winn voiced concerns about what we can do, and I believe that the first step is creating hope and identifying specific problems to address. This includes how and how much we are reimbursed as compared to the expectations of time invested. I am working with my state counseling association (Ohio Counseling Association) to create change at this level, which has to start with awareness and conversations. We have to make sure that our legislators and governments understand why we are burning out and what the expectations are for our industry, as they have significant influence through Medicaid/Medicare reimbursement.
I have some ideas of directions that we can go, but am looking forward to hearing from others. I’m optimistic that there are other counselors out there (including a great next generation that has not been institutionalized to our normal yet) with some creative and innovative ideas.
So, a simple next step: start the conversation! Reach out to your state organization, including Government Relations, Insurance Advocacy, and Political Action Committees, as well as others locally to get the conversation started. Many of them are already working toward this or aligned goals and need our help. Sometimes a single voice can speak for us, but sometimes the sea of counselors behind those voices need to be visible.
I have been meeting with heads of Health and Human Services, my state representatives and professional boards for years to no avail. I have taken financially challenged clients with me to speak with me to give them n opportunity to advocate for themselves. Often professionals doing evidence based research and training are absolutely ignorant of the realities therapists in the real world face. I absolutely respect your post.
Hi All,
I can only speak for Ohio, but I highly recommend reaching out to Martha Flemming in OCA. She has started an Insurance Advocacy committee that is working closely with specific people to get insurance reimbursement rates increased. Even if you are outside of the state of Ohio, you could do something similar. Usually, when individual practices advocate for their own rate increases, this doesn’t do much. We need to do this across the board in our states, not just individually.
Hi, I’m collectively organizing with a group of masters level graduate students to advocate for paid internships. I love that this article calls out unpaid internships as part of the reason for the burnout and undervaluation that is occurring. We’d love to plug in with any groups that are organizing on this nationally. Does anyone know of other groups organizing around this issue?
Thanks for saying this. I am a current MFT grad student and I agree with your statement. In New York State there is a shortage of MH counselors and now they increased our state credits to 60 from 45 for diagnostic privileges. Further, paying internships will help us minimize burn-out. Not only am I in grad school but I also work a full time job plus I have to do clinical hours that are unpaid. I would make more of an impact if I could get paid while working in my field. #paidinternshipsfor MH
Thank you so much for this article. Very much needed. I was thinking how I pay $90/hr for an acupuncturist and $80/hour for a massage therapist, and as a counselor at a college I get paid $35/hour although this is most recent. I was being paid $25/hour a couple of years ago. One frustrating aspect about college mental health is how they’ll say that the job actually pays more as we’re paying, let’s say, $49,000/year for 9 months so it’s “really'” $65,000/year. However, I’m not being paid that much per year so I have to still figure out on how to live on $49,000/year in an increasingly expensive region then now add 8.6% inflation!
I can speak to the insurance disparity in Florida. Many counselors refuse insurance due to the reimbursement rate. What most new counselors fail to realize is the paperwork associated with insurance. After an hourly rate of 60.00, you then have to submit for reimbursement and that is time consuming. When you average that time the mix, it is more like 55.00. Now also add in that you will most likely require a copay. This is let’s say 20.00, 9 or of 10 times is paid with a CC and now there is a fee deducted again. Now we are at 50.00. We have a EF file system which charges to bill, taking another 3.00 per submission. Now we are at 46.00. There is a 90 day window to receive payment from insurance. If there is a problem you wait on hold with all insurance companies min of an hour. All of this to say. There is additional cost to CE, rent, internet, electric. Sadly at a time when mental health is at the forefront of our countries crisis few counselor s take new clients due to insurance restrictions. Employers taunt insurance benefits that have such a small if any mental health coverage. There has to be a huge change to keep counselors and to bring
Counselors to the field. Desperate clients have been forced to private pay to even find a counselor. Change has to be requested by clients suffering as well.
Thank you for writing this as I resonate completely and have been preaching this. My wife is a medical professional and I work with Medical professionals daily. We do much of the same work, see the same clients, diagnosis and treat the same disorders yet see an UNREAL disparity in pay. It is tragic and unsustainable to be in this field when the need is exponential
I am currently an RN with. BSN . I would love to go back to school to be an LPC but the math is not working at all . I would spend approximately $40,000 for my education only to make less money even after I am licensed . There are paid internships in my area but they pay the same an our local convenience store chain . This doesn’t make sense at all to me .
In addition, if you are a School Psychologist and Licensed Professional Counselor, which requires an additional 100 hours beyond a master’s (EdS or PhD) your starting salary is $32000. Those of us that choose to work in the schools are the front line workers for students in crisis yet we are not paid for our education nor our experience. The only reason we work in the schools is we can be provide preventive care, get paid regardless of the client cancelling or no showing and better hours/ schedule. The stress is equal to if not more than working in private practice as our job security is dependent on administration who are not mental health providers and parents. We have to carry the same liability insurance and are mandated by FERPA and HIPPA.
The reimbursement rate of insurance companies is half of our hourly rate for those of us in private practice. Insurance companies require recredentialing every 90 days now. The initial credentialing process is an enormous amount of paperwork and then waiting sometimes 6 months to be approved. You have to be careful to recredential within the deadline or you get kicked out. This happened to me with my most productive EAP and I could not get back in as I was told no more therapists were needed in my area! I take insurance as if I did not, I would not have a practice at all. Many of us had to get rid of our offices due to Covid and then could not afford to open it again as practices decreased as a lot of folks want i-person visits. I cannot blame them. Things are a mess all the way around but we hope for the best and pray to God that He has our back. Yes more reimbursement would certainly help.
This is part of the problem, as someone mentioned above: “This is a field composed largely of minority populations.” Any profession comprised typically of non-white-old-men is paid less.
Another reason is that no one has raised this to legislators before. No one has done what Gen Z and Millennials are doing now: standing up for hiring managers to say, “That salary is not sufficient.” On the other hand, I’m seeing jobs posted in the Ohio Counseling Association and other professional organizations’ newsletters that offer decent sign-on bonuses. Also, when I spoke earlier this year with Brian Banks, the ACA’s lead government affairs liaison, he informed me upon my asking that the ACA does plan to take on student loan forgiveness. There’s a lot of it now but they require 10 years of work at a public agency. That’s an equation for burnout.
So I suggest standing up to hiring managers and advocating however you’re comfortable. As for paid internships, my understanding is that it’s a school decision. For instance, the book SURVIVING AND THRIVING IN YOUR COUNSELING PROGRAM, an ACA book by Drs. Jude and Julius Austin, mentions paid internships. The Chicago School of Professional Psychology, which I attend, does not. Yes, it is a consideration/plan to advocate for it. Can you imagine medical professionals doing unpaid internships?
SUBVERT THE PARADIGM!
I have a private practice in Arkansas and have just reached agency status and Medicaid and Joint Commission accrediation. I totally agree with everyone. I have decided when I opened to pay people that choose to work with me what I would like to make. That is why I pay my provisionally licensed professionals starting out the opportunity to make between $50,000 and $75,000 per year and if they are fully licensed up to $120,000 or more. They get to set their schedule and tell me when they have enough of a case load. I worked community mental health and did not agree with the way that clients were treated, staff were treated and providers not being respected or cared about. I know what we are worth as a provider and I know what we go through. I choose to not make as much money from providers and allow for my providers to take care of self and family so that they are able to be there for their clients. If more offices would do the same, we would have more healthy professionals that could take pride in helping others. I also pay for the CEUs and for their license renewals. We, as professionals deserve to be treated as such and taken care of the way that others with the same years of training and “student loan” balances are paid and taken care of. It is time to have a voice and be respected. I tell everyone that just as physicians and medical staff are expected to take care of our physical body, God as provided us with the position to take care of others mental health. I count it as a blessing and believe that that we deserve to be treated and paid as such.
Frankie Smith
transforminglivescounseling1@gmail.com
Transforming Lives Counseling LLC
I can’t say that I enjoyed the article; it is sad news for our profession. But I appreciate it. It’s a real life view of the stuggles we face and is a resource that can be shared. The general public needs to know these things so that they can support and advocate as well.
I don’t belive that withdrawing from insurances is necessarily the answer..Although I understand why so many are doing it.. I’ve considered it as well but my undeserved, predominately Medicaid community would not support private pay and I would have to drive 40 minutes to the next city, where counselors charge $200/hr. Louisiana the adult Medicaid reimbursement is $52 and $69 for children. It’s disheartening. What is happening is that noone accepts Medicaid, private pay is the only avenue, and these communities, the ones that need it most, are undeserved. But we do our best! We face the adversity with a smile. We are helpers and we find joy in that giving of ourselves to others. We deserve better. It is time that we have those conversations. But I fear if they are not louder conversations these disparities will continue to influence an already broken mental health system.
I am the co-owner/business manager of a mental health practice in the Chicago Suburbs and I completely agree. I come from a background in brand management working in Fortune 500 companies and until I got into healthcare I had no idea how insufficient and constraining reimbursement practices are in the mental health care industry. The recent economy and high inflation has further exacerbated these issues, leaving practices financially constrained with rising overhead costs and no way to combat them (most insurance companies have still not raised their reimbursement rates despite covid or current inflation…or quite frankly in any of the years prior). This is unacceptable and the reality is it will not change unless this issue becomes pressing and they have to deal with it.
The article above would be a perfect one to get published in a number of the leading news outlets as mental health has been on the forefront of the news since Covid. I encourage you to try to get this published in the New York Times, Associated Press, Washington Post and the like…and hopefully the plight of those in mental health will finally be heard.
It truly is disturbing to see how little Counselors get paid. The time and effort and money one puts into becoming a counselor is daunting. How do we go about demanding better pay for Counselors?
It is broken mental health system.
I really appreciated this article. Stagnant wages or economic disparity, I believe, is the root of all stress. I am an Independent Contractor, small business woman in private practice for 30 years. In addition to stagnant wages, I pay 20% taxes on my corporate earnings and another 22% taxes on my take home salary. It costs me $4,000 a month to run my small business; I pay my medical biller 7% of all profits.
My Health Insurance premiums are at $1,800 on the low end and $2,400 on the high end with $6,000 per family member deduct so, I go without. I paid the Obama Care fine of $10,000 over four years for being too poor to afford Health Insurance. Increased paperwork has gotten out of control. Lastly, audits have ramped up creating a culture of fear as audits frequently result in recoupment of funds for work done but for mistakes found by the auditor.
In 2008. i reported my medical biller to the state patrol. That state patrol officer retired at age 50 with full benefits. I have worked 17 years longer than him with no retirement in sight.