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Private practice has changed a LOT over the last few years… and therapists are still trying to figure out what comes next.
In this episode, Gordon talks with Lex E. Santi about the evolution of therapy after telehealth, online platforms, insurance shifts, and changing client expectations. They dive into why more clinicians are entering private practice, why clients still crave in-person connection, and how companies like BetterHelp, Alma, and Headway are reshaping the profession.
They also explore the pressure therapists feel to market themselves, build niches, and create an online presence in a rapidly changing industry. Toward the end of the conversation, Lex shares how writing, narrative therapy, mindfulness, and storytelling intersect in his clinical work and creative life.
Meet Lex E Santí 
Lex Enrico Santí is a therapist, clinical supervisor, and the founder of A Key Therapy PLLC, where he works at the intersection of evidence-based practice and the deeper human questions that bring people into therapy in the first place. Trained as a licensed clinical social worker and currently completing his doctorate at the University of Kentucky, Lex brings a grounded, integrative approach to his work — drawing on modalities like CBT, ACT, and mindfulness alongside his own framework for healing he calls the AMI model.
The son of Cuban immigrants and a former Peace Corps volunteer in Romania, Lex carries a lifelong fluency in crossing cultures — literally and emotionally. He speaks three languages and brings that same attunement to difference, displacement, and belonging into his clinical work. In the therapy room, he holds space for individuals navigating anxiety, identity, and the transitions that quietly reshape a life. He also supervises emerging clinicians, teaches workshops on meditation and understanding anxiety, and is building A Key Therapy into a group practice rooted in presence, curiosity, and care. He believes that good therapy — like good writing — is about learning to tell a truer story about yourself.
Beyond the therapy room, Lex is a published author with an MFA in Creative Writing from George Mason University — the author of four books of poetry and a collection of short stories and essays. A meditator and someone who thinks seriously about the spiritual dimensions of mental health, he lives in the Finger Lakes region of New York with his family. He is a proud husband, father, and has another child on the way.
Private Practice Looks Different Now Because the World Looks Different Now
Private practice has changed dramatically over the last few years. And while COVID may have been the thing that pushed a lot of those changes forward, the bigger conversation is about what therapy looks like now.
Therapists are navigating telehealth, in-person care, insurance shifts, private pay decisions, online directories, platforms like Alma and Headway, and the growing pressure to market themselves in ways that didn’t feel as necessary before.
For many clinicians, it can feel like the work itself is no longer enough. You are not just a therapist. You are also trying to figure out how to be visible, how to explain your niche, how to build trust online, and how to help the right clients find you.
Telehealth Changed the Way We Think About Therapy
Before COVID, telehealth was often seen as optional, unusual, or even a little suspicious. Some therapists wondered whether online therapy could really be as effective as in-person therapy. Clients had concerns too, especially around privacy, connection, and whether the experience would feel personal enough.
Then suddenly, telehealth became the norm.
For many therapists, it opened the door to a new kind of flexibility. Clinicians could see clients from home. Clients could fit therapy into busy schedules without commuting, parking, or rearranging their entire day. Practices could reduce overhead by not relying as heavily on office space.
But telehealth also brought new challenges.
Therapists had to think about camera placement, sound quality, privacy, distractions, and how to create a therapeutic environment through a screen. Clients were sometimes logging in from cars, errands, or places that were not ideal for therapy. The convenience was real, but so were the boundaries that had to be created around it.
Clients Still Want Human Connection
Even with the convenience of telehealth, many clients still want to be in the room with their therapist.
There is something different about face-to-face therapy. Being physically present with another person creates a kind of connection that can be hard to fully replicate online. For some clients, that in-person experience helps them feel more grounded, focused, and emotionally present.
This does not mean telehealth is bad or ineffective. In fact, for some people, telehealth or even phone sessions may feel more accessible. Some clients, especially those who are neurodivergent or have ADHD, may find it easier to regulate when they are walking, talking by phone, or not having to manage the intensity of face-to-face interaction.
The bigger point is that therapy is no longer one-size-fits-all.
Some clients thrive online. Some need the office. Some prefer a hybrid approach. And therapists are having to think more intentionally about what works best for their clients, their modality, and their own way of practicing.
Therapists Need Better Telehealth Training
One important issue is that many therapists were thrown into telehealth without much training.
Clinicians learned quickly because they had to. But that does not mean the field fully caught up with best practices. Many therapists never received formal training on how to do online therapy well. They were not necessarily taught how to manage the technology, reduce distractions, create emotional presence through a screen, or set boundaries when clients are not in an appropriate space for therapy.
That matters because telehealth is not just in-person therapy on a screen. It has its own clinical considerations.
The way a therapist sets up the room, uses eye contact, handles interruptions, manages privacy, and responds to a client’s environment all affect the experience. As telehealth continues to be part of private practice, therapists will need more thoughtful conversations about how to do it ethically and effectively.
Private Practice Has Become More Accessible
One of the biggest shifts in the field is how much easier it has become to start a private practice.
Today, a therapist can sign up for an EHR, create a Psychology Today profile, get connected with insurance platforms, and begin building a caseload much faster than before. Tools like SimplePractice, Alma, Headway, and other platforms have made parts of the private practice process feel more within reach.
This has changed the landscape.
Private practice used to feel like something therapists moved into later in their careers. Now, more clinicians are considering it earlier. Some are leaving agencies. Some are building part-time practices. Some are creating fully virtual businesses. Some are trying hybrid models with both insurance and private pay clients.
That accessibility is a good thing in many ways. But it also means there is more competition, more choice for clients, and more pressure for therapists to communicate clearly about who they help and how they work.
Insurance, Private Pay, and the Hybrid Model
The cash pay versus insurance conversation is still a major part of private practice.
Private pay can offer more freedom and potentially higher income per session, but it usually requires more intentional marketing. Therapists have to help clients understand the value of working with them, especially when clients have insurance benefits they want to use.
Insurance-based practices may have less need for marketing because clients are often actively searching for covered providers. But insurance also comes with its own challenges, including reimbursement rates, administrative demands, credentialing, and documentation requirements.
That is why many practices use a hybrid model.
A hybrid model allows clinicians to accept some insurance clients while also keeping space for private pay clients. It can offer stability while still creating room for flexibility and growth. But it also requires therapists to understand the business side of practice and make decisions that align with their goals, values, and capacity.
Platforms Like Alma and Headway Are Changing the Industry
Platforms like Alma and Headway have shifted the way many therapists think about insurance.
For some clinicians, these platforms have made it easier to accept insurance without handling every part of credentialing and billing alone. For clients, they have made it easier to search for a therapist who takes their insurance and has availability.
But these platforms also change the competitive landscape.
Clients now have access to many therapists across their state, especially with telehealth. This means therapists are not just competing with providers down the street. They may be listed alongside dozens or hundreds of clinicians who offer similar services online.
That makes differentiation more important.
Therapists need to be clear about who they serve, what they specialize in, and why a client might connect with them specifically. Not in a gimmicky way, but in a way that helps clients make informed choices.
Niching Matters More Than Ever
A strong niche helps clients know whether you are a good fit.
Just because a therapist accepts a client’s insurance does not mean they are the right therapist for that client. Fit still matters. Training matters. Personality matters. Clinical approach matters. Lived experience, specialization, and communication style can all influence whether therapy feels useful and safe.
Niching helps therapists communicate that more clearly.
When a therapist tries to speak to everyone, their message can become too general. But when they are clear about the kinds of clients they work best with, it becomes easier for the right people to find them.
This does not mean therapists need to box themselves in forever. But it does mean that in a crowded and increasingly online marketplace, clarity matters.
Therapists Are Being Asked to Market Themselves
A lot of therapists did not go into this field because they wanted to sell themselves.
Most therapists want to sit with clients, do meaningful work, and let that work speak for itself. But the modern private practice world often asks for more. It asks therapists to write bios, create content, show up online, explain their approach, and make themselves visible.
That can feel uncomfortable.
There is a tension between being a clinician and being a business owner. Therapists have to think about ethics, professionalism, vulnerability, visibility, and boundaries. They have to decide what parts of themselves belong in their marketing and what parts should stay private.
But marketing does not have to mean becoming someone you are not.
At its best, marketing is simply helping the right clients understand who you are, how you work, and whether you might be able to help them. It is not about performing. It is about clarity and connection.
Therapy Is Becoming More Convenient, But Also More Complicated
Clients want convenience. Therapists want sustainability. Technology makes both more possible, but it also adds complexity.
A client may want to log in from anywhere, use insurance, find someone quickly, and schedule outside traditional hours. A therapist may want flexibility, boundaries, meaningful work, and a practice that supports their life.
Those needs do not always line up perfectly.
Private practice owners are now having to think through questions that did not feel as urgent before. Do I offer telehealth, in-person, or both? Do I accept insurance? Do I join a platform? Do I build a niche? Do I market on social media? Do I need an office? How do I protect my time? How do I create a practice that is both accessible and sustainable?
These are not small questions. They shape the future of the profession.
Writing and Narrative Therapy Can Help Clients Heal
Toward the end of the conversation, Lex shared how his background as a writer connects with his work as a therapist.
Writing can be a powerful tool in therapy because it helps people approach their stories in a different way. Sometimes a client returns to the same injury or painful memory over and over again, and traditional interventions may not seem to move it. In those moments, writing can create a new path.
A letter, a journal entry, or a creative exercise can help someone externalize the story and relate to it differently.
Narrative therapy recognizes that the stories people tell themselves matter. The meaning we make of our experiences can shape how we see ourselves, our relationships, and our possibilities for healing. Writing gives those stories a place to go. It can help clients process, reframe, grieve, release, or simply understand what they have been carrying.
The Future of Private Practice Is Still Taking Shape
Private practice is not what it used to be, and it is still changing.
Telehealth is here to stay in some form. Clients are more informed and more selective. Insurance platforms are reshaping access. Therapists are thinking more carefully about niche, marketing, and sustainability. And the profession as a whole is still trying to figure out what modern therapy should look like.
There are challenges in all of this, but there are also opportunities.
Therapists have more ways to build practices that fit their lives. Clients have more ways to access care. The field has more room for creativity, specialization, and flexibility.
But at the center of it all, the work is still about connection.
Whether therapy happens in an office, on a screen, or over the phone, the heart of the work remains the same: helping people feel seen, supported, and understood.
Gordon Brewer: Well, hello everyone, and welcome again to the podcast. Looking forward to you hearing from my guest today, Lex E Santí. Welcome, Lex.
Lex E Santi: Thanks, Gordon. Thanks for having me. I'm so glad to be on the podcast.
Gordon Brewer: Yes, and we were kinda d- talking a little bit before we started just about life and, uh, the shared, uh, shared names and all that sort of thing-
which is interesting, and the intersection of his Cuban culture with my Anglo-Saxon culture and all that sort of thing. But, uh, Lex, as I start with everyone, tell folks a little bit more about yourself and how you've landed where you've landed.
Lex E Santi: Thank you so much. Yes, I am uh, currently located in the beautiful Finger Lakes of central New York.
We are about four hours away from everything, including Philadelphia, New York City, and Toronto, smack dab in the Finger Lakes. There's 11 Finger Lakes, and I'm at, um, uh, close to Ithaca, New York. I'm a little bit north of that in Trumansburg, New York. I revolved throughout life and grew up in this area, but then I left for about 15 years and have made a home here with my son, whose name is Gordon, which brings us-
to the shared affinity- Yeah, yeah ... to the name Gordon.
Gordon Brewer: Yes. Good, great. Yeah, and so, uh, Lex, you're a licensed clinical social worker and have- That's correct ... have specialized in a lot of kinda different areas. But, um, I know one of the things we wanted to talk about was just how things have changed for us in private practice, um, since COVID.
I mean, it's a, it's- Absolutely ... always interesting how that is such a huge marker in time for all of us a- at least in, in this time of history. But, um, yeah, so I'm curious to see how you h- how you see that things have changed since then. And I, you know, I can chime in 'cause I c- Sure ... I know I'm noticing a lot of the same things.
Lex E Santi: Yeah, I'm interested in your point of view as well, Gordon. I think it's been, um, it's been a really interesting time in the field of therapy and in private practices. Uh, my private practice ironically started- In March of COVID year w- year zero, and I literally had a office space that I was subletting two days a week in downtown Ithaca, and used it twice on two days, and then everything shut down.
Mm. And so I was stuck with a lease right in the... I was, I was like, "This private practice thing isn't, uh- Oh, no ... it could be a total waste of time and, and- Mm ... and money. What am I gonna do?" And so then I remember going home, and I was amazed that my clients didn't fall off. And suddenly every... I was starting to get booked, and I was working at the same time as a clinic.
So all my evenings and early morning hours and lunches w- became filled with clients. And it didn't really slow down until really this last year. And slow down, you know, I, I think I'd put that in quotes. I think I kinda have chosen to go from, you know, 10 to 15 people on a regular basis, you know, down to, you know, a few that I've been holding on- Mm
along with working full time at Cornell University.
But it's a, it's been a fascinating run, and I think the advent of technology, the placement of what therapy can do to a traumatized culture, how it could help a traumatized culture and people, has been really evident. And- Mm-hmm ... and we know that therapists around the country, their hours filled up, and there was a real need.
And the call to arms of people to go back to school has been ringing really loudly. And the reassessment of our place in society has been a conversation that's been mixed though, right? Mm-hmm. It's on one hand we've been hearing we really need therapists. People really need therapy. So-and-so needs therapy.
He's in the news all the time. You can tell he's got damaged stuff with his parents that need to be repaired. Mm-hmm. Or so- if only so-and-so could repair their inner child, they would donate more money to the cause. Mm-hmm. You know? But- Yeah ... we're at the same time hearing things from the current administration that says, "You're not a professional degree program, and we probably can't take out loans enough for, for university anymore."
You know? Mm-hmm. And there's also been a real alarm bell that's been ringing that's saying, "We need you back in the office full time. You can't have... You can't stay at home, and you can't work from home. That doesn't work anymore. Your clients need you," et cetera. I think it's been a shift. I'm now 50.
This is, my career that I chose after 15 years of life and experiences where I said, "You know, I really wanna become a therapist," and I already- I'd had the degree. And so my experience really went from clinic work in person, high-need population, to then private practice and clinic work, and now I'm primarily working with college students and doing private practice.
So it's been an interesting run, Gordon. I mean, I, I really took that- Yeah ... in different ways. Please, go ahead.
Gordon Brewer: Yeah. Yeah, it's, uh, yeah, you know, it's, it's interesting because I know, uh, just thinking back when COVID hit everybody was scrambling to go online with therapy, I mean, as far as doing telehealth and that sort of thing, which, uh, before COVID, that was just a novelty kind of thing.
You know, you're offering online therapy and a lot of people were kind of, uh, kinda um... What's the word I'm looking for? A little bit suspicious of it or feeling-
Lex E Santi: Oh, yeah ...
Gordon Brewer: feeling like- Yeah ... uh, okay, it's not going to be as effective. It's not going to, You know, wor- worries about privacy, all of those kinds of things.
But COVID ushered in that telehealth and working with people online to be the norm, and then you've got just ano- another whole tangent we could probably go on is just the advent of tech companies getting into the mental healthcare, things like y- um- Oh,
Lex E Santi: yeah ...
Gordon Brewer: Help- BetterHelp and things like that.
Lex E Santi: BetterHelp,
Gordon Brewer: Headway-
Lex E Santi: Um ... Alma. Uh,
Gordon Brewer: yeah. Yeah. Yeah, all of those. Everybody got, has
Lex E Santi: gotten in.
Gordon Brewer: And so, but I think, uh, to your point, though, what we're seeing, at least in my practices, is that people are preferring to come in face-to-face.
Lex E Santi: Sure.
Gordon Brewer: And, um, uh, you know, I've only got a handful of clients I see online, but the vast majority are coming into the office.
Lex E Santi: Mm-hmm.
Gordon Brewer: And so I think it just, uh, it's, um, I think it says something about the, our, all of our need for that human contact and that face-to-face, being in the room and being present, uh- Absolutely ... in 3D, in 3D rather than 2D. So, I mean- Yeah ... it's just... Yeah.
Lex E Santi: Yeah, and I think I'm not against in-person therapy at all.
I think it- Mm-hmm ... it has its place. I think what the issue raises is as a profession- Number one what are the best practices of doing online therapy- Mm-hmm ... in order to balance a private practice that a- that allows portability of our license, you know? And, and- Right ... our licenses for the most part allow us to be practicing anywhere and our clients must be in the state of licensure.
And- Yeah ... um, at least it is for LCSWs, and I, I'm- Yeah ... in the middle of doing my DSW right now, too, so. Mm-hmm. And the, the experience that I have is that so that's number one. Number two is the question of, well, how much training, if any, have we gotten to do best practices of telehealth? Right, and, and that is a big whopping zero in the- Mm-hmm ... agencies that I have worked for. There has never been one training or not even verily a sound bite of what is- Right ... the best practices. How your camera is set up, how your sound is set up. Um- Mm-hmm ... how, you know, the distractibility that could happen, and people pick up on that.
Can you imagine in... And that happens with telehealth with an increasing frequency comparatively to being in person. So of course- Right ... people are gonna prefer this. You know, it's, it- Right ... you know, we wanna be in the same room with each other when you know your therapist isn't distracted. I think there's great- Mm
utility in doing telehealth, and it certainly helps the field and the profession in, in- Mm-hmm ... professionalizing it, allowing us to do additional work. Right, right. Not to mention supervision and other aspects that can be- really expand our ability- Right ... to get together.
Gordon Brewer: Yeah. And, and, and, and I would add to that not only the distractibility of the therapist, but of the client.
Um- Absolutely, sure ... I know that was a, that was an issue I know I ran into several times where-
Lex E Santi: Mm-hmm ...
Gordon Brewer: people were trying to, uh, trying to do therapy while driving. Um- Oh, yeah. Yeah ... yeah, and, and, and it just, uh, yeah, and they were, you know, out running errands or something like that, and so- Right ... it just really-
Lex E Santi: Oh, yeah
Gordon Brewer: really made, made it difficult. And quite frankly, it felt- Yeah ... a little disrespectful of, uh, you know, the time, but- Totally.
Lex E Santi: I had somebody log in while he was in his hot tub.
Gordon Brewer: Oh,
Lex E Santi: wow. And, and I said, "Are you sure you don't wanna put a shirt on, and you can get more comfortable someplace, and we can," you know.
Mm-hmm. He said, "No, I'm good. I just, uh, I'm all right. I just, you know, I just wanted to sit in the hot tub and talk to you a little bit."
Gordon Brewer: Yeah, yeah.
Lex E Santi: And I was like- Right ... "Well, I don't know if that works. You should, you sh- we should probably find another time. Call me back in five minutes." Um- Mm ... I also think, you know, there's great possibility of looking at who performs- or who performs, you know, as if clients perform in therapy is the wrong word.
But to what to what degree does someone enjoy conversing in telehealth, in person, and is there any difference be- between being on the phone? I've been surprised. Mm-hmm. Some clients are able to regulate and slow down, especially if they're neurodivergent or have ADHD. Mm-hmm. They suddenly kind of, "Oh, I don't, I'm not so distracted when I'm just on the phone with somebody.
I can just look at- Mm-hmm ... you know, I could just go for a walk and talk to you."
Gordon Brewer: Mm-hmm.
Lex E Santi: Mm-hmm. And so I think that's an interesting thing that still hasn't been really measured out, and- Right. Right ... um, there have been some studies that have pointed to it being as effective. Whether we feel that, whether we feel as attuned to our clients and our clients feel attuned to us, I think it matters client to client and c- clinician to clinician.
Gordon Brewer: Yeah. And I, and, and I think, too, it's dependent, too, on, uh, the modalities that we use as far as- Absolutely ... our
Lex E Santi: preferred- Oh,
Gordon Brewer: yeah ... you know, theory or, or approach.
Lex E Santi: Oh, yeah.
Gordon Brewer: Um, you know, it's, uh... I know with my therapist, I've been doing some EMDR. Mm-hmm.
Lex E Santi: And
Gordon Brewer: we've be- we've been able to do it online with the use of a an app that has a, a bilateral stimulating dot that goes- Yeah
back and forth, and it, it's working for me. Um-
Lex E Santi: Cool
Gordon Brewer: And so yeah.
Lex E Santi: That's great. That's great. Yeah. Yeah, and I've- Yeah ... I've pretty much, I've done you know, my own therapy with my clinicians, and I think it's been mostly been, since COVID, online, you know? And it's- Yeah ... and I've found it- Sure ... to be very effective.
Gordon Brewer: Yeah. You know, the other thing, too, is, is that what I've seen in just in consulting with people and that sort of thing is, is that a lot of people have, um, going into private practice have just said, "I just want to do online."
Lex E Santi: Yeah.
Gordon Brewer: Um, and again, it's, um, you know, the, the convenience of that and the, the cost savings of not having to you know, either lease an office or own a building or whatever is pretty huge with all of that.
Oh, sure. Sure. And so being able to weigh all of that out, used to be the problem is, is that, uh, insurance wouldn't pay for telehealth, but that's no, because of COVID, you know, that's no longer the case. And so- Mm-hmm ... yeah. And so, yeah. And so there's a lot of things that we've, uh, I, I think have really adjusted to and changed in just a short period of time.
Lex E Santi: Um-
Gordon Brewer: Yeah I'm,
Lex E Santi: I'm glad you mentioned that because I think the relationship to time is a really great factor, and if you found yourself, you know, it was during COVID it was a health risk, and it was a health risk to therapists, um- Mm-hmm ... especially when we had, our clinic would sometimes see, I don't know, 500 to 600 people a day, for 30- Wow
30 clinicians. So-
Gordon Brewer: Yeah ...
Lex E Santi: so we would be, it would've been impossible. But the- Mm-hmm ... but the c- but the relationship that we all have with time has definitely crunched. I mean-
...
Lex E Santi: Google and Facebook and Instagram and every single other social media company's fighting for just nanoseconds of our time, just a little bit of attention, a little bit of attention.
Right. And now being able to log in, jump on your call, and then jump off and go back to your life does matter, you know? Mm-hmm. I mean, that's the thing. And so trying to- Right ... to figure out where we fit into that relationship. Right. Yeah. Well, I know- Um, as opposed to parking the car and getting some place and then arriving and then say, "I'm here," and then leaving and then going to- Right
arrange your entire day,
Gordon Brewer: yeah, and that just the travel time and that sort of thing, I know.
Lex E Santi: Yeah.
Gordon Brewer: Yeah, that's a, a big thing. And so-
Lex E Santi: Mm-hmm ...
Gordon Brewer: yeah, so, um, one of the things that I, I think I wonder about with all of this is, um, how do you think private practice itself has changed with the way we do things now?
I think so many more people are going into private practice, at least I'm seeing that.
Lex E Santi: Yeah.
Gordon Brewer: And, um, I think it's, uh, it used to be that, uh, that was kind of an outlier for somebody to go into private practice, but now it's seems to be something that m- more and more clinicians are doing.
Lex E Santi: I think that's a great question, and I think we have seen because of COVID and because of the shift that companies like Alma and Headway, um, the insurance carriers that have been whitelisted through those organizations and that have- Mm-hmm
that are fronting reimbursement costs, uh, for us, we, it's suddenly everything's within reach. And while it's been interesting to see from private practice starting right at COVID, where it went from a place of Everyone was cash paying, seeking reimbursement, you know? Yeah. And then once Headway and Alma started to take off that has seemingly dried up.
And or I- in my experience, it's mostly dried up to a great extent, and people really wanna use, and you see this in the list serves that I'm involved with too- Mm-hmm ... the people really wanna use their insurance. So I think I'm taking this question in two ways. One is, how have the clients changed?
And two, what does it allow therapists to have within grasp? You can sign up for SimplePractice tomorrow, you can sign up for a number of different organizations, and you can have, you know, five to 10 clients. Now, if you're not a s- if you're not specialized and you don't have a ton of experience, it may be hard to find your client group and to find people that really wanna glom onto you.
This is, I have a similar profession in writing, and I was a writer before I was a therapist, and I think not every writer wants to sell themselves. I think that's the same thing. You had a podcast episode with a marketer, which I thought was a really interesting episode that you did, Gordon.
Mm-hmm. Where you were, you talked a lot about, that marketer was really talking about, well, how do you do this, and how do you offload this part of your life? And that's, that's challenging, that's intimidating- Yeah ... and it's exhausting to do. Yeah. This podcast is a direct relationship to being able to talk about themselves, and a lot of therapists are like, "I just wanna be in my room and I wanna take care of my clients."
Mm-hmm. "I wanna help people, and I wanna-" Right ..."I wanna let that work speak for itself." Has the game dramatically changed that we all have to suddenly become stories in ourselves? Mm-hmm. I don't know. Mm-hmm. Uh, but I know that it's part of what I do in my private practice, which is called Akey Therapy, and it's all about mindfulness, and it's about all about trying to find other therapists that are into mindfulness, to connect with clients that are into that, and I think that is part of our work now.
And- Mm-hmm ... in trying to sell ourselves, I think every profession is in this developmental state. You see teachers trying to TikTokify themselves and trying to tell you- Mm-hmm ..."Look at what I can do with my students." What are the measures of our outcomes, mm-hmm. Is this modern life and society? I don't, I'm not sure where it's all headed.
Yeah. But I just- Right ... I know that it's part of what we're grappling with and what we're wrestling with as a profession.
Gordon Brewer: Right. I think, uh, and too is that balance between what, what clients are expecting out of therapy, uh, versus what we as clinical people think is best, I'm using air quotes here, of, for the client.
And, um, I think we have to really- Pay attention to that. But you're you're correct. I know one of the big things in just, again, in, in working with people, different private practice owners or people going into private practice over the years, you know, there has to be uh, at some point you make this decision around, okay, do I wanna be strictly cash pay as far as what I do as far as how I create income for myself, or do I want to accept insurance reimbursement and that sort of thing?
And so you have- Right ... to weigh all the payoffs of that- Mm-hmm ... um, which is r- r- really in my, my mind just something really simple. If you're, if you're gonna be strictly cash pay, you are gonna have to, uh, devote some energy and time and money into marketing your practice to get your name out there so that people can find you and that sort of thing.
Whereas, a- and you can potentially get more per session versus being, uh, accepting insurance with all that goes with that. The thing is, is that you don't have to do much marketing if you're accepting insurance. It just kind of comes to you, at least that's been my experience in my practice. I mean, we do a little bit of marketing, but basically my marking, marketing budget in my practice is pretty much zero.
And so, um, yeah. And it's because we have we, we do what I, I like to refer to as a hybrid model. We accept both cash pay and insurance-based clients,
Lex E Santi: so. That's right. That's right. That's right. And, and I'm hybrid, too, and I would say that the, it's I think because it's so, you know, the, because a lot of the insurance companies to figure out who is covered and then- Mm-hmm
you know, I mean, I've, I don't know the last time that I logged into Aetna to try to figure something out inside of their- Mm-hmm ... system or any insurance company to try to figure- Right ... out who is covered inside of this. You know, it's like-
Gordon Brewer: Yeah ...
Lex E Santi: you might c- call the provider directly, look on Psychology Today to figure it out, but y- you are likely to go to the source and go as quickly as possible to that- Mm-hmm
uh, as a- Yeah ... client. And as a clinician, we know that we're in a industry that has seemingly unlimited potential. We're competing against people all across our state. So again, this goes back to in-person versus, versus telehealth or, or who- Mm-hmm ... you know, what is the specific thing that you wanna work with?
Who's going to connect with you? What is the degree type? Whatever that choice is, those choices are that the client potentially has is gonna be where they reach out and what- Mm-hmm ... makes sense to them. Right. And I think, so I think Alma and Headway and other places have increased- The reach in both directions.
It's been a bilateral connection for both people, and that we're trying to understand. I think, I think we are going to have to ... maybe not market is, is the wrong word. It sounds so, you know, like- Mm-hmm ... we're suddenly selling Crisco to the, you know- ... to, to housewives or something like that.
Yeah. But like, it's a, it's a place of, you know, we have to identify ourself or differentiate ourselves. Mm-hmm. You know? It's like I- Yeah ... I struggle every month to know, do I wanna pay this $30 to Psychology Today again? It's like, I guess so. Somebody else might get that client, you know? So I go- Yeah
okay, I'll just go ahead. Right. That's another place where my name is, uh, coexisting with other folks.
Gordon Brewer: Well, I think that's al- also the, the importance of creating a niche for yourself- Mm-hmm ... I think is, is r- is really, this is where that comes in as far as making sure that the clients that are reaching you are a good fit for you and you're a good fit for them.
And, and- Right ... I think there's a lot of, uh, there's a, an education curve. You know, it, just because I accept your insurance doesn't mean I'm gonna be a good fit for you as a therapist.
Lex E Santi: Absolutely. Absolutely. Yeah. I mean, I tell a lot of- And
Gordon Brewer: so I think,
Lex E Santi: yeah ... I was just gonna say, I tell a lot of clients, I said, "This is, part of your relationship to therapy might be firing me."
Gordon Brewer: Mm-hmm.
Lex E Santi: You know, that it's, uh, that it's okay to let go of this relationship. It might be, you know, we work for a little bit, we get through what's done and say, "Okay, I'm just ready to move on." Yeah. I think it's an interesting profession that we don't get a bonus whether it goes well or it doesn't go well.
Right. That, you know, and that and that part of our experience is sort of unknowable, mm-hmm. I'll have people reach out to me five years later and will say, "You changed my life," and I'm like, "That's wonderful. I don't remember what we worked on," you know? Yeah. And they'll be like, "I don't know either, but I'm really-" Yeah
"glad we were there together."
Gordon Brewer: Yeah. It happens. Yeah, that kind- So ... of thing happens all the time.
Lex E Santi: Right? It's a really- Yeah. Right ... interesting profession for that reason. It's like- Right ... we totally are in somebody's lives, and then they just, we just walk away from each other, and it's like- Mm-hmm
it's time to move on. Right.
Gordon Brewer: Yeah.
Lex E Santi: Yeah.
Gordon Brewer: Well, um, to, Lex, to shift gears a little bit before- Sure ... we close out. Yeah. Um, talk about your, the intersection of being a writer and being a therapist and-
Lex E Santi: Sure.
Gordon Brewer: Sure ... uh, some of your work, your creative work.
Lex E Santi: I, yeah, therapy started in a way it predates me writing and it continues past writing in, in, in a way.
I've always, I've always connected with other people through writing, both in giving people writing and also receiving writing and editing it. And I did a master's in fine arts before I did my master's in social work at Washington University in St. Louis, and the MFA is a highly competitive degree. We read each other's short stories and poetry and edit it and give feedback, and I ran a literary journal before I, went to my MSW program.
So I've f- found myself in a position over the course of the past five years where I've been really trying to integrate these two parts- Mm-hmm ... uh, which were very distinct parts of my life. One was more creative and out there and, you know, reading and poetry readings and publishing short stories of other people and myself.
And lately, what my work has in- been involved with, w- has been both using narrative therapy in sessions and helping clients recover from trauma and allowing them to read, write, and process things that have happened, which I think has been an extremely p- powerful part which integrates with mindfulness, integrates with understanding your life as- Mm-hmm
a series of events that are your curriculum to work with. And then inside of my own work, I've published now four collections of short story... I mean, four collections of poetry, a collection of short stories, essays, and I just published my first novel, which is all about, uh, found family, healing, and trying to get free in, in- Mm-hmm
in American society. So it's- Right ... it's been a really fun ride.
Gordon Brewer: Oh, yeah. That's fascinating. And, and no surprises that you gravitate to narrative therapy with that, with that, uh, that background, which I, I'm a big fan of narrative work as well. I mean, it's just, yeah, I think our stories are, are important, and particularly the stories we tell ourselves about what's going on in our lives is huge.
Lex E Santi: Absolutely. Yeah. Yeah. Absolutely. It's been a real, It's been fantastic. At Cornell University, I've done a program for four years called Write It Out, which allows groups of clients, uh, work through their stories that they've been holding onto and that they wanna let go of. Mm-hmm. I sometimes find when we're in the therapy room with someone and they keep on coming back to a story or an injury over and over again, and we just can't...
It doesn't matter the technique you use. You can't use CBT on it. You can't use DBT. You can't use mindfulness. You can't have a meditate. You could use... You can't do systems work with it. I then turn to, "Let's write about this." You know, maybe it's a letter- Mm-hmm ... that you need to write to the person who's the injury, or you need to come at it- Mm-hmm
in a creative way. Right. That then allows them to rewire it, and I've done it with myself- ... and it's been extremely, extremely powerful.
Gordon Brewer: Yeah. It's g- that's so, so true, and I know in my own- Yeah ... my own routine is I journal every single day, and it's just, um- Oh, it's so important ... it's, uh, yeah, it just, um, i- there's something that happens.
And, and, and journaling by actually writing as opposed to typing it out I think is huge. Um-
Lex E Santi: Oh, sure. Sure.
Gordon Brewer: Yeah. I, I
Lex E Santi: sometimes find- I think we
Gordon Brewer: process it differently, yeah ...
Lex E Santi: I sometimes find the work of just simply g- I tell my client, Just writing dear so-and-so out in a, in, on paper or on a computer has an enormous amount of psychological benefit for you because- Right
there is part of the individual that's so used to that story being X, that the idea that they would spend time with it and actually write dear so-and-so causes a switch. Now, what I often find is that we might get stuck for weeks at a time on that part, which then wants you so ... You can hear also some of the IFS language that also I work with in- Mm-hmm
in this practice, and that then the client then says, "Okay, I, I'm stuck here. I don't, I don't wanna do it." I say, "Well, we talk about it every week. Let's, why not do it?" And they say, "Well, I don't wanna waste any more time." Right. And I say, "Well, we're wasting time here. What's the difference?" So it's a fascinating process to get there.
Gordon Brewer: Yeah.
Lex E Santi: Uh, and it's one that I, I try to spend time with in my novel and trying to ... So it's the story of someone who's trying to get away. They've been captured and stuck inside of paying off a debt that they didn't know, that they didn't realize that they had taken on. And it's got tropes of of urban legends and gangsters and s- Mm-hmm
drug running and that sort of stuff, but it's really fun. But the interesting parallel in my own life is that the same amount of money that the character had been trying to pay off for 10 years, um, by the time I finished the novel, it was the same amount of money that I paid off from doing my public student loan forgiveness from doing my master's in social work.
Wow. It's a really interesting thing that I didn't plan out, but I realized after I published the book, I said, "It was a half million dollars in the, in this novel, and true to life, it's a half million dollars that the federal government paid back for me doing 10 years of service as a social worker."
Mm-hmm. Wow. So everybody should go out and buy it. It's The Song of the Midnight Rider. Yeah. And, uh, it's available on Amazon
Gordon Brewer: and
Lex E Santi: various places.
Gordon Brewer: Okay. Well, I'm looki- looking forward to getting my hands on that. I can't wait. Yeah, send it to you So, uh, Lex, I know, um, I know it's, uh, we've gotta be mindful of your time in all of this, but, uh, tell folks how they can get in touch and where to find your book and all that sort of stuff.
Lex E Santi: Sure. Sure. I am ... You can find me at akeytherapy.co. That's A-key, A-K-E-Y therapy.co or https://www.lexenricosanti.com, and I'm also on all the socials, um, and some derivation of that. Sure. And, uh, thanks so much, Gordon. This is amazing.
Gordon Brewer: Yeah, it is, and we'll have those links in the show notes and the show summary- Cool
for people to get to easily. But Lex, it's been a pleasure chatting with you.
Lex E Santi: I hope you can- It's a real pleasure. It's an honor. Your podcast is amazing, Gordon. You know, you are a cert- Well ... you are a saint in this industry, and I really thank you for your time.
Gordon Brewer: You're very kind to say that.
Thanks.
Lex E Santi: Thank you, sir. Okay.
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