Solving the Supervision Crisis in Mental Health with Rachel Ledbetter

Rachel Ledbetter (00:00):

Clinical supervision wouldn't have been solved by somebody outside of the profession. Investors didn't even know what that term meant. And so I feel like therapists have a unique vantage point of knowing what are the biggest problems that are facing our industry and what are the ideas to solve them.

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Michael Fulwiler (00:19):

This is Heard Business School where we sit down with private practice owners and industry experts to learn about the business of therapy together. I'm your host, Michael Fulwiler. Rachel Ledbetter, welcome to the show.

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Rachel Ledbetter (00:36):

Hi. Yes, glad to be here. Thanks for having me.

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Michael Fulwiler (00:39):

Excited to have you on. I'm still getting used to your new old last name.

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Rachel Ledbetter (00:43):

You know what? Same here. There's so many times that I start to say my old last name and then I go back to my old last name. It really is a thing about which one's easier to pronounce my married name for those who are just listening, I just got divorced and for my married name was McCrickard, which was like, just kill me. It was awful. So Ledbetter is also not a walk in the park, but it is easier than McCrickard.

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Michael Fulwiler (01:13):

Could be Fulwiler. So.

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Rachel Ledbetter (01:14):

Fulwiler. That's right. Yeah.

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Michael Fulwiler (01:18):

You have been open.

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Rachel Ledbetter (01:18):

How do people usually pronounce your name incorrectly?

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Michael Fulwiler (01:22):

Fulwiler.

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Rachel Ledbetter (01:23):

Usually Fulwiler. Yes.

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Michael Fulwiler (01:26):

I was going to ask, you've been open about your divorce. Divorce is always challenging. I have thought about as a therapist, especially as a marriage and family therapist, is it especially difficult?

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Rachel Ledbetter (01:39):

That's an interesting question. I would say it's especially easier.

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Michael Fulwiler (01:44):

Interesting.

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Rachel Ledbetter (01:44):

I don't know that that's true or not, but I know a lot of divorce therapists and I think that therapists are oftentimes very growth-minded, very growth oriented, and I think that I'm making some generalizations here, but I would say that for a lot of therapists who want to continue to grow, if they feel like their relationship isn't growing, then it's a hard thing for them to recognize, especially when so much of the work of therapy is around listening to your inner voice and not self abandoning and all of those kinds of things. I think there's a lot less, and it could be just a generational issue too, that I think that nowadays there's a lot less pressure to stay in something that isn't serving you. So I definitely didn't feel any shame associated with the divorce. I felt more just a lot of just proud of myself for making the decision that was right. So I don't know how other therapists I'd be curious to know, but I definitely didn't feel pressured to stay in the marriage because I'm a therapist.

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Michael Fulwiler (02:52):

That makes sense. I spent the first part of my career working at the Gottman Institute, which I talked about on this show. One of the takeaways for me as someone who's not a therapist from working there is ending a relationship is not always a bad thing. Sometimes it's actually the healthiest outcome, and there is a lot of shame around divorce, especially I think within certain communities within, or faith-based communities in the church. There's this pressure to stay together. There's a lot of stigma around divorce, which actually is a natural segue. Love to jump into your, I didn't find that into your educational records.

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Rachel Ledbetter (03:30):

I love that. That's where we started though.

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Michael Fulwiler (03:31):

Yeah. So you actually went to biblical school as an undergrad. You went to...

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Rachel Ledbetter (03:38):

Milligan.

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Michael Fulwiler (03:39):

Milligan in Tennessee, studied theology. Can you tell me about that and when you changed your mind from theology to therapy?

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Rachel Ledbetter (03:49):

Yeah. The name of the degree was Bible Ministry, which I just think is so interesting. I'm like, what did I think I was going to do with that? But I think back then I was raised in the church. It was a very huge part of my life in a lot of ways. I feel like I'm beginning to return to that in some interesting ways that I could talk for an hour about just overcoming the grief associated with church and all of that sort of stuff. But it was a very big part of my upbringing and something that was super important to me. And back when I was in undergrad, Beth Moore, she was a spiritual teacher, kind of focused on, there was almost every woman I knew was in some sort of little group study about a Beth Moore's latest book. And so I think I thought, okay, I'll do something like that.

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(04:37):

And my college was also, it was a bit progressive in the sense that growing up we were taught that women couldn't even speak in the church or have rules of authority, and Milligan was different than that. They very much encouraged me to use my voice and kind of nurture that and all of that sort of stuff. But I think when I graduated, and then my former husband had majored in film, and so we decided to move to LA. He got a job at DreamWorks, and so we moved out there and I just thought, well, I'm not ready to be telling anybody what they should be doing in their spiritual journey. I just felt like too young and inexperienced. So that's what kind of led me to pursue a grad degree. And I thought marriage and family therapy feels like it would line up with my theology kind of focus through the process of my grad degree, I kind of just began to go, okay, now I just want to do therapy and not incorporate my religious piece into it. But that's kind of where it started.

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Michael Fulwiler (05:36):

And do you feel like you were kind of moving away from that foundation of the church, or were you thinking that you would integrate it into your therapy practice at some point once you got out of graduate school as a faith-based therapist?

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Rachel Ledbetter (05:48):

Yeah, I think that there's probably differing views on the idea of Christian counseling. There's a lot of people who want faith incorporated into their therapy process, but even though I went to a faith-based grad school, I went to Azusa Pacific University, they were really big on the kind of ethical boundaries of introducing your own political views or religious views into your relationship with your clients is something that's more about you than it is about them. And I know a lot of therapists who do counsel from a faith-based perspective who just say they do it if the client requests it, but they're not leading with that. So I think it changed my mentality. A little bit of faith is something that is important to me, but to make that assumption that it was going to be important to my clients was something that I started to deprioritize, I guess.

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Michael Fulwiler (06:41):

So you get your degree from Azusa Pacific. Did you stay in California or did you move back?

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Rachel Ledbetter (06:45):

We did. We stayed for about seven years after that. And my first grad school, post-grad school job was working in Skid Row in downtown Los Angeles with chronically homeless adults. And it was a work that I felt excited by. I really was drawn to that community and very focused on whatever I could do to help there. So I learned a lot. It was very much front lines. It was also a bit out of necessity as well during that time. And I don't know how it is in LA now, but during that time it was very hard to get a job as a therapist if you weren't bilingual. Most of the community mental health organizations in LA required Spanish speaking therapists because so much of the population was primarily Spanish speaking. So without having that piece, I was a little bit more limited in the jobs that were available to me right out of grad school.

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Michael Fulwiler (07:35):

And then when did you move back to Georgia?

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Rachel Ledbetter (07:37):

Moved back 2011 to rural north Georgia, right under Chattanooga, Tennessee. I'm from Ringgold, Georgia and continued collecting hours towards licensure, which that's part of my story of struggle, had to do with the fact that there's more MFTs in California than there is the rest of the country combined. So when I moved home to rural North Georgia and needed to continue getting LMFT supervision, there weren't any supervisors in Georgia that met that qualification within a drivable distance.

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Michael Fulwiler (08:11):

So what did you do?

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Rachel Ledbetter (08:12):

Yeah, well, I found one that was in Atlanta and was driving two hours each week to meet with her face-to-face. I worked at a community mental health organization, a great one called Georgia Hope, and they didn't have an LMFT, so I paid out of pocket for the additional MFT supervision hours that I needed to get licensed in Georgia. Found a supervisor and just really lost a day of work every Friday by driving to her office meeting with her an hour for an hour and then driving two hours home.

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Michael Fulwiler (08:41):

Was virtual supervision not a thing?

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Rachel Ledbetter (08:44):

It was not allowed the state? No. They passed by the state, the law in Georgia in 2015.

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Michael Fulwiler (08:48):

And so is this where the idea then for Motivo came from?

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Rachel Ledbetter (08:53):

Yes. Yes. It very much is. Yeah. So after I got licensed, I then became a clinical supervisor an AAMFT Approved Supervisor, just so that we'd have more in the area that I lived in, and so that the organization I worked for could hire MFT Associates as well. So went through that process. So I was staying close to what the rules and regulations were in Georgia. So I saw it change in 2015, and then I thought that would've been so much easier to have a video conference as an option. Video conference as a whole was still a little bit new to the therapy profession. We probably we're looking at it the same way that therapists are looking at AI now. A little bit of a, I'm not sure about this kind of approach, but out of a necessity perspective of just like is it ideal to not have a supervisor that you could just pop over into the next office? No, but it's better than nothing. That was kind of my first thought about it.

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Michael Fulwiler (09:51):

And then this idea comes to you. How did the actual business start? What was the first step that you took to put this into action?

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Rachel Ledbetter (10:03):

I saw my brother start a business. He started a business in Chattanooga, a whiskey company. And I was like somewhat, yeah, I was somewhat, I was just paying attention to what he was doing. And so I started to learn a thing or two about what it looks like to start a business, what it looks like to raise money from investors, that sort of thing. And I told him my idea. I told a couple people my idea, and they were like, that's just a really good idea to create this platform of clinical supervisors that are available to associates who don't have a supervisor in their area. That was kind of the initial idea. I remember seeing my husband, he was updating his company's website, worked for a carpet company, and they were using this Shopify template to upload a bunch of carpet samples. And I was like, I'll just buy that Shopify template and put up supervisor profiles, and instead of the carpet description, I'll put supervisor descriptions and just see if that works. And people start clicking on it and adding to their supervisor. And then on the back end, I can match people together. It was very manual, actually. It was very manual for the first several years of just on a Shopify website matching people together. I had no idea what I was doing. I didn't have an engineer or any sort of tech person on the team. I was just kind of doing it on my own to see what it looked like.

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Michael Fulwiler (11:27):

And so are therapists signing up as supervisors at the time?

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Rachel Ledbetter (11:30):

Yeah.

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Michael Fulwiler (11:30):

How are you getting the word out about it?

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Rachel Ledbetter (11:33):

In the early days, it was very much just kind of word of mouth. I was a part of the GAMFT, the Georgia Association of Marriage and Family Therapists. The original company name was called LMFT Connect, so it was only MFT supervisors during that day. But then really quickly, we started getting requests for social work, supervision, addiction counseling, professional counseling. So we expanded pretty quickly into the other licensure types. It just was kind of lucky in the sense that I reached out to different professional associations like AAMFT and ACA, American Counseling Association and just said, this is what I have, is it of interest from a affiliate partnership perspective? And they were like, yes. We have a very hard time finding services that just sell directly to therapists, especially ones where there isn't a lot of market saturation. It'd be hard for ACA or AAMFT to pick from the very many digital health platforms or electronic medical records and endorse one. But because we were the first supervision provider, they felt like, oh, we could kind of endorse Motivo since there isn't any competition for it. So that's what brought in the initial influxes of supervisor. We got hundreds and hundreds of supervisors just from those emails, those partnerships.

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Michael Fulwiler (12:54):

And what was the business model initially? Was it revenue share?

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Rachel Ledbetter (12:57):

Yeah, it's always been marketplace. We set the rate for supervision, really committed to accessible supervision. So we set the rate, we take a cut of it, and the supervisor splits it with us. So supervisor gets part, we get part, and that's what it's always been.

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Michael Fulwiler (13:13):

Have the rates changed over time or have they been the same?

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Rachel Ledbetter (13:17):

No, we mostly kept them pretty similarly. What the margin that we were taking in the early days was very low. I think this, that's just what happens when a therapist starts a company. I was moving five bucks a session and thought I could grow a company off of it. So we had to change that a little bit over time, but the rates really began to change more when we started working with organizations. So in the early days, it was very B2C business to consumer. The therapist was paying out of pocket for supervision, but once the pandemic hit and all states changed their rules to allow supervision virtually, it really opened up an opportunity for our main customers to be the employers of counselors. So think Youth Villages, Catholic Charities, departments of mental health for different counties, large hospital systems and treatment centers. That's mainly who we serve today, and they're paying for supervision on behalf of their therapists.

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Michael Fulwiler (14:15):

I read an article where the rates were referenced. I'm curious if this is still what they are today. $65 for individual session, 55 for dyadic and 45 for group supervision. Is that what the supervisee or the organization pays to Motivo?

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Rachel Ledbetter (14:31):

That's changed definitely from...

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Michael Fulwiler (14:33):

That was what it was previously.

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Rachel Ledbetter (14:34):

Yeah, that's what it was previously. It's 75 now for individual, I think 65 for dyad, 55 for group, but it's more for organizations who are using Motivo mainly because we do a lot more for them in terms of and hour tracking and that sort of stuff.

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Michael Fulwiler (14:54):

And so initially, was it individual supervisee, so associates and interns that were seeking supervision, finding a supervisor on Motivo, and over time it shifted more towards Motivo contracting with organizations are more of a B2B model.

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Rachel Ledbetter (15:10):

That's right. That's right. I would say we've never stopped doing the B2C, but we don't focus a whole lot on it. It's mostly B2B, and we really encourage the organizations that employ therapists to cover supervision on behalf of their employees. It's kind of table stakes now. Most people can get a job where supervision is included. I think that's the right thing for organizations to do. So that's really where our focus is today.

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Michael Fulwiler (15:36):

And is it mostly with community mental health agencies? Because at a group practice, my understanding is if you're a intern or associate, you get supervision typically from the...

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Rachel Ledbetter (15:47):

Yeah, that's right. Some group practice managers utilize us. If they just don't have the bandwidth to offer supervision or they want their supervisees to be trained in a specific modality or something like that, they'll come to us. But mostly what we're doing is community mental health. Yes. Hospital systems, 87% of the people who are using Motivo, the associates live in a mental health professional shortage area. So it's very rural, underserved clinicians that are utilizing our platform, most of them working with the Medicaid population under the umbrella of a community mental health center.

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Michael Fulwiler (16:24):

I've also heard you reference the statistic that 57% of at least folks who obtain a master's degree in counseling never get licensed.

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Rachel Ledbetter (16:34):

That's right.

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Michael Fulwiler (16:34):

I'm sure supervision is a big part of that. Yeah.

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Rachel Ledbetter (16:36):

Yes. And social work as well. Yeah, there's a lot of barriers that exist, but yeah, we're losing over half of the available supply of therapists in that very last mile towards licensure.

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Michael Fulwiler (16:48):

It makes sense. This problem that a lot of startups are trying to solve around accessibility of therapy tends to be focused more on how to find a therapist or how to match with a therapist. But the problem of actually producing more therapists and helping more therapists to get licensed isn't one that's received a lot of attention. And so I remember when I first heard about Motivo, I was like, oh yeah, this totally, totally makes sense. And I think so much of it, it came out of your own experience and your own problem that you were solving for yourself, which so many companies start that way. I'm curious, you start on Shopify, is there a certain point where you're like, okay, I have something here that's time to get more serious about it?

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Rachel Ledbetter (17:33):

Yes.

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Michael Fulwiler (17:33):

And what was that point?

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Rachel Ledbetter (17:35):

I went into Techstars Atlanta at this accelerator program for startups, three months. They kind of incubate your startup and give you a lot of resources and information and also some funding. I think it was $125,000 that you get as part of that program to just get started. So that's when I made my first hire an engineer and started to think through, okay, how do we actually turn this into a product that can scale rather than a spreadsheet that I'm just manually tracking and helping people meet that way? And those probably started the hardest years of Motivo, and I feel like therapists could probably even relate to this, especially from a private practice perspective, that when you're kind of starting out, you're kind of like eyes wide open, so excited, honeymoon period, you're putting out your single for your private practice, you're just excited about what's to come.

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(18:29):

And then the hard work starts of how do you actually grow this thing dealing with all of the things they didn't teach us in grad school around marketing and accounting and sales and all of that sort of stuff. Those were the really tough years of Motivo for me personally, of just having to do things that were out of my depth that I didn't really have the money to pay for great talent to help me with that. They call it the trough of sorrow in the startup world of just those kind of push the boulder up the hill part of it. It was awful.

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Michael Fulwiler (19:04):

I remember seeing a photo of your Techstars Accelerator group, I think you're one of two or three women in the picture, and he joked that there was never a line for the women's bathroom.

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Rachel Ledbetter (19:16):

That's true. That's very true.

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Michael Fulwiler (19:18):

Tech tends to be very male dominated. So I'm curious for you as therapist, as a female therapist especially, what was that like in tech trying to build this startup and also starting to meet with investors and just try to break into this new world?

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Rachel Ledbetter (19:34):

Yeah, the interesting thing about that Techstars picture, there were 10 companies. Yeah, there were only two of us, me and Lauren, who Lauren had a legal tech company called Case Status. That's still doing quite well. And then all the other eight founders were men, but also all the people on all the teams, the men's team were all men as well. So it was just like a whole bunch of men. They couldn't have been more supportive of us. And I feel like there hasn't been enough funding available to women founders, particularly women of color. But I would say that because of that, there was a really big focus on it. So a lot of the investors that Motivo have only invest in female-founded companies. So I didn't really feel that kind of gender holdback. I felt more of people saying, let's make space for great companies and great ideas. And the gender piece was a bit irrelevant for me.

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Michael Fulwiler (20:32):

You mentioned investors. How did you make the decision to seek outside investment, especially from venture capital when there's, I think a lot of feelings about venture capital in the mental health space? How did you make that decision to seek investment instead of trying to bootstrap?

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Rachel Ledbetter (20:48):

I didn't know anything about what I was doing. And so when I went to Techstars, I thought, this is great. This will be a helpful incubator. Right off the bat, they're giving me money, so that's an investment. They're taking some of ownership in the company for that. And then Cox Enterprises, they're the financial backer of Techstars Atlanta. They're really focused on how can they bring more innovation and entrepreneurship to Atlanta and the southeast. And so that's what they wanted. They wanted great companies being built in the southeast, and they took a vested interest in Motivo as a place that they thought was doing social good in the world. Most of our investors are actually what you call impact investors, meaning that they care just as much about the social good of your platform as they do the financial returns. And I think that's one thing that probably gets lost in the world of LinkedIn, of kind of a bit of a misunderstanding of venture capital.

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(21:45):

There's all different kinds of venture capitalists, just like there's all different types of therapists and there's really great therapists, and then there's therapists who aren't so great. There's teachers that are really great, and then there's teachers that aren't so great. Kind of the same thing there. So I didn't really know enough about venture capital to turn up my nose to it. I just knew the people that I was meeting were so invested in Motivo's mission. They never, and I think I've told you this before, Michael, my investors have never asked me to make a decision that wasn't supportive of the mental health industry. That wasn't the best decision for my therapists and clients ever in lieu of being able to grow faster or to charge more, never. I know that that happens, and I don't want to pretend that it doesn't. I know that there is a lot of really unfortunate things that happen in venture capital, but Motivo didn't experience it.

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Michael Fulwiler (22:45):

But that said, do you think venture capital and the investment of venture dollars into the mental health space has been a net positive or net negative for the field?

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Rachel Ledbetter (22:56):

Motivo wouldn't exist without it. And I say that because I'm not an engineer. The days of bootstrapping really, in my opinion, come out of two sources. You're an engineer yourself and you can build a product, you can build it. I couldn't build it. I needed high priced engineers to build a product for me that I couldn't have paid for that out of my own pocket, or people who've had success before and are using their own capital to start their next company. Those are the things that I see bootstrap working with. I couldn't have done it. I couldn't have brought Motivo to where it is today on my own dime. So for me, it was a necessity. I guess it's just an individual choice. I think it's an important thing. And I put a deck out there that's everything I ever learned about fundraising. And a lot of it just has to do with like, is venture capital even right for you?

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(23:50):

I mean, most of the time when we were raising money, we got nos most of the time because most of the time investors would look at Motivo and they'd say, nobody has ever questioned whether or not we're solving a real problem. Almost every investor questioned whether or not it would be big enough to justify venture funding. And it's turned out that it is. Supervision is a big enough problem. The need for more mental health therapists is a big enough problem. But that wasn't necessarily the rhetoric in the early days of building the company, and I didn't know how to change that. I was also like, I don't know if this is a billion dollar company. I don't think so, but I don't know for sure.

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Michael Fulwiler (24:32):

I also think it's important to distinguish the type of company that you're building, which is similar to a business like Heard where we're not a therapy delivery platform. And the economies of scale with those platforms typically result in therapists being underpaid because the dollars have to come from somewhere. And so the business that you're building, the business that we're building at Heard, it's not about how do we scale mental healthcare by pain therapists as little as possible. And I think that there's this perception of, oh, that's a tech company. Motivo is a tech company. They're one of these companies that pays therapists really poorly or something like that. And so I think tech companies tend to get lumped together. And I know I'm preaching to the choir here, but I think it is an important point to make.

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Rachel Ledbetter (25:19):

I think it is too. Yeah, and I mean, it's something that we listen to often from our supervisors trying to make sure that we are sticking to our original mission of accessible and affordable clinical supervision. There's a lot of markets out there. I'm thinking Oregon and Washington State where the going rate for clinical supervision is $200 an hour, and I find that to be a bit of a burden for an associate therapist and for a community mental health organization that's employing them. And so there's a mission piece of it. Could we charge more and pay more? Yes, we probably could, but then I would be going back on what my mission was with Motivo, which was to create a more accessible and affordable path to licensure. The other thing that I very much considered over the years was just letting supervisors pick their own rate.

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(26:14):

They asked me that a lot, why don't we just pick our own rate and let the market decide? But I put myself back in the shoes of an associate therapist and I would've picked the cheapest supervisor. I would've just scrolled through and found the cheapest out of necessity. And so I wanted to give people the opportunity to pick their supervisor based on clinical fit rather than who's the cheapest. So that's the reason I never decided to go that route. I don't know if it's the right decision or not, but it's the decision that I made.

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Michael Fulwiler (26:44):

That makes sense.

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Rachel Ledbetter (26:45):

Yeah.

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Michael Fulwiler (26:45):

What about the therapist? Who do you say, well, I have 20, 30 years of experience. I deserve to charge $200 for supervision. My cash pay rate is 2 50, 2 75, $300 for therapy. Why would I charge less per supervision? How would you respond to that?

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Rachel Ledbetter (27:01):

I would say I agree that Motivo's probably not the right fit for you. Motivo's a great fit for supervisors that are saying, I love doing supervision. I want to pay it forward to the next generation of therapists. I can relate to how hard it is in community mental health to be able to find great supervision, and I want to do a little bit to give back. And those are the supervisors that utilize Motivo. And I have zero judgment for any supervisor who's like, that's not the point I'm at in my career. I'm either building my own private practice, I live in a high cost of living area. I have too much experience for that. But what we found on Motivo is that there's not usually a correlation between supervisor quality and rate. We have amazing supervisors who are very happy with the rates that they receive from Motivo because they're not doing it because they're trying to make $200 an hour. They're doing it to give back.

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Michael Fulwiler (28:05):

And I think it's important to note that if a therapist is getting less for supervision, offering supervision through Motivo, it's not like that money is going in your pocket.

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Rachel Ledbetter (28:14):

That's right.

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Michael Fulwiler (28:16):

Just a lower cost for the person who's receiving the supervision.

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Rachel Ledbetter (28:19):

That's right. Yes. Yeah. Motivo is not yet a profitable company as a lot of startups, and we also do supervision scholarships. So if people come to us and they can't pay anything, we still pay the supervisor and don't charge the supervisee for their financial hardship situations. We want to do more and more of that as we get profitable. That's just part of our give back mission. But yeah, I'm not getting rich off of Motivo.

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Michael Fulwiler (28:46):

The model reminds me of Open Path Collective.

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Rachel Ledbetter (28:49):

It's great.

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Michael Fulwiler (28:50):

We had Paul Fugelsang on the show, and in a kind of similar model, the therapist offers more affordable therapy or they agree to take clients for 40, $50 a session, whatever the amount is, and so it's a way to increase access to affordable therapy and what you're building. It sounds like it's really about increasing access to affordable supervision in the same way.

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Rachel Ledbetter (29:12):

That's right. Yeah. A lot of overlap there. I love what Paul's doing, and I think a lot of clinicians, they have what they have in their self-pay private practices, but most of them do want to give back in some way. And so if they can carve out a limited number of hours per week that they either do supervision or sliding scale therapy, a lot of therapists are drawn to that opportunity.

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Michael Fulwiler (29:37):

I'd love to talk about lessons that you've learned building Motivo. There's a few that you've talked about on LinkedIn. One is around giving difficult feedback, and it sounds like that was feedback that you received from your own team. Could you tell me about that?

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Rachel Ledbetter (29:51):

Yeah, it's hard. I'm a three on the Enneagram. I like to be liked. I like to be admired and thought, well, love when I read this quote the other day that said, your Enneagram number is not who you are. It's like who you are not. And that really stuck with me. This idea of how do I get comfortable with having to give hard feedback that might change the way that people feel about me, that's more about me, and that's more about my own ego than it is about anything else. So a lot of work in my own therapy has helped me be able to not self abandon. I love what Brené Brown says about Clear is kind when you're giving clear and constructive feedback. That's like the kindest thing that you can do for your employee, for your team. I've learned a lot about that.

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(30:39):

I would say that was not true of me in the beginning of Motivo either the way I interacted with supervisors, the way I interacted with my team. I think I've learned a lot about what that looks like, and I'm much better at it than I am now, and I try to just center what does this person need? This person needs and deserves clear and honest feedback from me. I'm also just very much like I'm not a very hierarchical person, so I am as interested in their feedback for me as I am in my feedback for them right now. I'm actually in the process of doing a skip level meeting with every person in the company just to hear what would you do differently if you were in my shoes? What are your biggest challenges that you're facing at the company? How can we make it a better place to work for you? I'm just trying to hear their advice.

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Michael Fulwiler (31:28):

I think that resonates, especially with group practice owners who are listening in a startup. There's obviously a lot of pressure, especially when you're looking at your burn rate and cash in the bank. You mentioned you're not profitable, so it's like every month you're actually losing money. It's like, we got to move here and grow, and if this person isn't performing or maybe it's not the right fit, it's like we need to do something or move them out. Whereas maybe in a group practice, it's not necessarily the case in terms of the amount of pressure, but I think also being able to have those difficult conversations is still important. And it's interesting, when I've talked to group practice owners, my expectation would be that the difficult part of growing and scaling a group practice would be, well, now you have to get more clients and you have to do more marketing. And now I'm more focused on the business and it's actually the people. And I've heard that it's the firing. It's the difficult conversations. It's the hr. That's the most difficult part of being a group practice owner. It's actually less about the business and more about the people.

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Rachel Ledbetter (32:27):

Yeah, it makes sense, right? It does. I remember this story that Ben Caldwell, he's one of my favorite clinicians out in California. He also wrote a book called Saving Psychotherapy that I just love. And he opens the book telling about this conference that he went to. Marsha Linehan was speaking, who's the creator of DBT, and someone, a clinician in the audience was opening a candy wrapper really, really, really loudly. And you couldn't even hear Marsha. The audio wasn't that great either. At the conference, you couldn't even hear her because of how loud it was. And he's looking around and seeing that all these other clinicians are rolling their eyes being super annoyed at this clinician for not being more aware or whatever. He went over and just said gently to her like, Hey, that's super loud and distracting. And she was so apologetic about it, but he was reflecting on the fact that here's a group of clinicians altogether who can't even tell this one person, Hey, that was too loud. Sometimes we have to remind ourselves these are the skills that we have uniquely learned. It's why I think clinicians can do a variety of jobs because basically what our master's degree is, and as human development and communication and emotional intelligence, that's what we know. So that in the workplace, in a variety of different job functions is so valuable.

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Michael Fulwiler (33:46):

And the other stuff you can learn, you have joked on LinkedIn like, you don't know what amortization means.

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Rachel Ledbetter (33:52):

I don't. And die never knowing what

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Michael Fulwiler (33:54):

It means, right? Still dunno. And that's okay, right? There's other people who know that stuff. You don't have to know those things or you can learn those things. It's like you don't have to know that in order to be a founder or CEO or a private practice owner.

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Rachel Ledbetter (34:07):

That's right. Actually, I think the most powerful thing that you can do as a company leader is know what you're good at and know what you need to hire out for, what you need real talented people around you for that. Motivo has gotten so much better over the last few years of just being able to afford and also hiring great talent in every department.

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Michael Fulwiler (34:29):

Another lesson that you shared, I think that you shared it in your newsletter, which is it Motivo Mondays still?

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Rachel Ledbetter (34:35):

Mondays with Motivo.

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Michael Fulwiler (34:36):

Mondays with Motivo, which is great. Definitely recommend subscribing to that. You've talked about how to separate your worth and value from your company's success.

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Rachel Ledbetter (34:44):

Me too.

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Michael Fulwiler (34:45):

Yeah. Can you tell me about that?

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Rachel Ledbetter (34:46):

Still doing it right. I mean, I feel like I've made a lot of strides in this way, and to be honest, kind of to our initial conversation around the divorce, I think that there's a lot of ways that I kind of self-medicated an unhappy marriage by putting myself fully into work mode. I mean, if I read the description of workaholism, it checks out of where I was a couple of years ago. I think the pandemic added to that as well. I don't know if other people struggled with different forms of isms during the pandemic. I think they did probably, but things were just, they weren't balanced. And so where I found my identity increasingly so was through work. And I can remember every time I would get on a plane, I would hope that the person sitting next to me would ask me what I did for a living so that I could brag about Motivo.

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Michael Fulwiler (35:35):

Like the opposite of what most therapists.

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Rachel Ledbetter (35:38):

That's true. That's so true. Yes. And every dinner party, I mean, women oftentimes get asked about children and family. I don't have children, but that's what a lot of times women get asked about and men get asked about what they do, and I always wanted people to ask me about what I do. And I've done a lot of internal family systems work with my therapist, Bridget, and that part of me, that performer part that need to get external validation, that voice has gotten a lot quieter over the last year or two, and I'm grateful for that. And it has not been easy. It's been with intentional work that I have said my worth and value, it is not wrapped up in Motivo's, success in my marriage, success in my appearance, anything like that. My worth is not up for debate. So that's been some work that I've done.

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(36:26):

I love Carl Jung's quote about the last four. What does it say? Something like everything before that is just research. I'm 44. So much of the first half of my life was about experiencing things, learning who I am, going through my own hard times and traumas and that sort of stuff. Now I feel like I'm in this phase of just like, who am I? What am I learning about myself? Who do I want to be? Not necessarily relying on old patterns and thoughts and behaviors to rule who I am today. So that's where I am now.

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Michael Fulwiler (37:02):

I love that. As you're building Motivo and you're making difficult decisions, are there certain values that are guiding you as a founder?

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Rachel Ledbetter (37:11):

Yeah, vulnerability is a big one for me. I don't do it for this reason. It's very in tune with who I am. But I would say that it's so disarming for people when you approach people, your employees, the people that you work around, your family, your friends with just a lot of the stuff that the Gottmans teach around I statements and owning my own side of the street. I actually was on this call with someone here recently, a colleague that she had done something that kind of threw me off in a meeting, and I didn't respond in a way that I felt proud of. And so I started the meeting by just acknowledging that and apologizing for it, and she immediately did the same. And the way that it put us on the same playing field of human to human connection was so powerful. So I'd say that's a big piece. My team would definitely say that they feel like I'm not a fake. I say what I think to a fault. Oftentimes I'm just very vulnerable and authentic. I would say that's probably my biggest gift. I have a lot of drawbacks, but that's probably the main value that I think I lead with.

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Michael Fulwiler (38:20):

Externally, it also, it looks like you lean into humor a lot as well, which I think helps build the positive culture, but leaning into that and not being the serious CEO and founder, that there's something to be said about that. It creates a culture of playfulness. We had Dr. Emily Anhalt on the show who just wrote the book Flex Your Feelings, and she talked about humor and playfulness and how much value there is in your own emotional health, but I imagine in workplace culture as well.

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Rachel Ledbetter (38:54):

Yeah, I think we should try to have fun while we're doing this. There's very serious stuff that happens for all of us, and life is scary in lots of different ways. So if you can make work enjoyable and not forced enjoyment, but very natural, real enjoyment, I think it's a win-win for everybody.

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Michael Fulwiler (39:15):

Definitely. So for therapists who are listening who are interested in getting into tech, what advice would you have for them if it feels kind of out of reach.

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Rachel Ledbetter (39:25):

I will say this, and I hate saying this, I'll probably kind of contradict myself a little bit. So clinical supervision wouldn't have been solved by somebody outside of the profession. Investors didn't even know what that term meant, and so I feel like therapists have a unique vantage point of knowing what are the biggest problems that are facing our industry and what are the ideas to solve them? Therapists also make great company leaders because they keep their ego in check. They focus on their own growth and development, and they prioritize emotional intelligence For all of those reasons, I would say therapists make great founders. I would say the drawback of that is that the market has been absolutely saturated with mental health startups over the last five to 10 years. It is not an easy time to start a mental health company right now. It was 10 years ago, it was five years ago.

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(40:17):

It's not today. Funding is not very well available to, there were a million what I call, or what the industry would call point solutions, meaning this type of care model delivered virtually for PTSD, this type, NOCD does that. This type of care model for eating disorder, Equip does that. There's all these different great startups who are meeting unique needs. Their only person to sell that to or health plans and health plans have grown tired of hearing startup pitches. They can't keep track of all the different options that are available to their members. So I would say the first thing you have to know is who are you selling to? If you're selling to health plans, it's an uphill battle. It takes years and years. You have to do funding because you're not going to even see a contract for three years or large employers. That's a different thing. Or B2C, which B2C you usually don't need. Investor funding for B2C is not usually a high growth opportunity. So there's more I could say about that. And I love, by the way, talking to early stage founders and mental health. So if I can ever be helpful, please feel free to throw my email in the show notes because I like throwing around ideas.

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Michael Fulwiler (41:34):

What about for therapists who are interested in consulting or contracting or working with a mental health company, not necessarily interested in founding a startup, but they want to get involved and work in some capacity?

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Rachel Ledbetter (41:47):

I think it's hard. We have always been strong from a clinical leadership perspective. Obviously I'm a clinician. We have a chief clinical officer, Dr. Carla Smith, who have a VP of compliance, Dr. Hermia. They have led the clinical side of the company so much so that for us, having clinical leadership in our engineering department is not something that we need because they work so close with the clinical department. I would say look at the makeup of the company and see what their clinical leadership looks like today and if there are some holes in it. But I would say most startups have some form of clinical leadership. If it's not in the C-suite or the CEO themselves, they've probably have that covered consulting. I don't love consulting. I've worked with a ton of consultants over time. It's hard. I would have a hard time being a consultant.

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(42:41):

I don't know enough about Heard's business to feel like I could come in and be valuable in a consultative way. Maybe that's underselling myself, but I'm just like, no, you guys are the ones who are in this every single day. It's going to take me a while to either learn what you guys are doing there to be able to be valuable, or I think consultants are high priced for little value. That sounds awful for me to say. I'm like, that's kind of how I feel. Because if you're not in it in the day to day, how do you know?

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Michael Fulwiler (43:10):

Right. Yeah. No, I think it's valid. As someone who's done consulting, I think that's very true. I think that my response to that would be when you're in it and someone now who is on the brand side is like you're just in it every day and you don't see things, or maybe you have blind spots to things where someone external, whether it's a consultant or an advisor may ask, well, why are you doing it that way? Or Why did you decide to set this up like this? And you're like, oh, I don't know. I guess I didn't really think about. That's just the way that it was before. So I think having some external perspective, someone who's not super close to it can be helpful. But I also agree you also miss context, right? Because you're not in the business every day.

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Rachel Ledbetter (43:52):

That's right. Yes. No, I think you're right about that. And advisors, I have used a lot. I love advisors, but consultants, sometimes it can be hit or miss depending on what the problem is.

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Michael Fulwiler (44:02):

Yeah, I think the joke about consultants is they come in and they don't understand your business, but then they tell you what to do, and then they're not responsible for actually doing any of the work. Correct?

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Rachel Ledbetter (44:12):

Yes.

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Michael Fulwiler (44:13):

And then they charge a lot of money. So if you can do that, great. But I think the thing is you actually have to deliver value. So as a therapist to consult with a business who doesn't have clinical leadership could be valuable if there is an actual gap there. And I think the company also needs to be serious about it too, and they're not just bringing someone in for optics to put them on their website and check a box. It's like they're actually serious about the work and not causing harm and all of those things.

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Rachel Ledbetter (44:43):

Absolutely. Yeah, I agree with that.

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Michael Fulwiler (44:45):

So we're coming to the end here. I'm curious, what does the future of Motivo look like if you're able to share a little bit about that with us?

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Rachel Ledbetter (44:53):

Yeah, I mean, I think one of the kryptonites of startups is when you start to kind of look like Frankenstein, because trying to diversify what you do and what you focus on and all of that sort of stuff. I think for me, what I keep coming back to is how can we solve this problem really, really, really well? I don't like it when I go to a website for a startup or some sort of company, and I'm like, I can't tell what they do because they do so much. And so every time Motivo has gotten distracted by shiny objects, it's always a mistake, and it's usually me who's made the mistake, but it's always like, let's come back to what do we do better than anybody else? We have great clinical supervisors and we provide a lot of value to community mental health centers who can't afford or find great clinical supervisors in their area.

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(45:43):

So that's what we do, and I think that I just want to continue doing that. We work with probably about 150 community mental health organizations today. There's about 22,000. There's many opportunities for us to continue to grow and evolve and be impactful to local communities who need more mental health clinicians. That's where I want to focus. I think there could be some other opportunities for us. We've never struggled to have enough clinical supervisors. We have about 1500 active on our platform today, and we have about 3000 on our wait list waiting for opportunities to supervise with Motivo. So we're also beginning to think about what could we utilize them for? If they're just looking for five additional hours a week of some type of clinical work, can we outsource some of their work to some of our partners that need virtual mental health counseling? We're thinking about that a little bit, almost like staffing agency for lack of a better term, but we are kind of thinking, how else can we help build a gap of there's not enough providers.

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Michael Fulwiler (46:46):

There's also a natural opportunity to offer continuing education. I would imagine once people become supervised, now they need CEUs to maintain their license. There's also opportunity to expand beyond just behavioral health. So I imagine these are all internal conversations that you're having.

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Rachel Ledbetter (47:03):

Yes. I looked a lot at that. Expanding beyond. There's a lot of speech and language pathologists, occupational therapists who need these supervised hours. Difference in other professions is that they don't pay for it. It's seen as a pay it full thing. My sister is an interpreter for the deaf, and she had to do this for other people. She does it all the time. They're helping them with their hours, but she doesn't get paid for it, and I just don't know enough about those industries. I don't think we'll ever expand outside of behavioral health, at least under my leadership, because I don't know enough about those other industries and don't care to learn.

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Michael Fulwiler (47:35):

Who knows? Things change so fast. Right. All right. Coming to the end here, I have a few rapid fire questions.

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Rachel Ledbetter (47:42):

Well, I love rapid fire questions.

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Michael Fulwiler (47:43):

Wrap this up. What's the hardest part about being a startup CEO that you weren't expecting?

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Rachel Ledbetter (47:49):

Oh, that's a good question. I think just like the relentless mind chatter, there's always something to think about. There's always something to do. There's always something to think about. That's hard.

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Michael Fulwiler (48:01):

I can see that. Who is a startup CEO or founder that you admire?

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Rachel Ledbetter (48:05):

Oh, I have great admiration for Harry Ritter, the founder of Alma. I love Christina Safran from Equip, Solome Tibebu from Behavioral Health Tech. There are many. Nikki Tessler from BeMe. These are just great people. When I think about them and their companies, I think, I don't know on a deep level everything about their company, but in terms of mission-driven people who are here for the right reason and who haven't abandoned their values, those are people that come to mind.

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Michael Fulwiler (48:36):

How much of a role has luck and timing played in the success?

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Rachel Ledbetter (48:40):

A hundred percent. 100%. I'm very big on that. I'm very big on that. It's everything. It is. Everything. Motivo 10 years ago wouldn't have worked. Motivo five years from now wouldn't have worked. If the pandemic didn't happen, Motivo probably wouldn't be in business today. It had that big of a shift on licensure rules and regulations, timing and luck are everything. Everything. I was in the right place at the right time. Did I have a great idea? Yes. Did I work really, really hard? Absolutely. I have an amazing team. I'm not saying anything against the work and time and all of that that we put into Motivo. There's a million reasons that startups fail and a lot of them don't have to do with how good the idea was.

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Michael Fulwiler (49:24):

For a therapist listening who's going through divorce or has recently been through divorce, what message would you send to them?

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Rachel Ledbetter (49:30):

Congratulations. It gets better. I read the book called Radical Awakening, which read it, and you'll probably leave your Marriage Women, very new woman. But it's a powerful book about just owning your own life and your own story. And let me just kind of acknowledge here. I don't have children. I think when you have children, it's a whole different ball game. I see. And acknowledge that, but for me at least, it has been an awakening for me of returning to some of the core parts of who I am, and I love being divorced.

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Michael Fulwiler (50:08):

I love the journey that you're on. And finally, what's one thing you want therapists to take away from this conversation?

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Rachel Ledbetter (50:13):

I want therapists to be a little less throw the baby out with the bath water. When it comes to tech and investing, I feel like it's one of those things you don't know until you're in it. And so if you haven't raised money before, if you haven't started a company, if you haven't interacted with investors, you don't really know exactly what the industry looks like. And again, I don't want to take anything away from the fact that there has been a lot of bad actors out there and things that have happened in venture that are horrible and egregious and that I've probably hurt our profession in certain ways. But there's been a lot of good, a lot of good, and a lot of moving society forward that I think is really important and good to not lose sight of.

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Michael Fulwiler (50:58):

Agreed. Well said. Rachel, thank you so much for coming on the show. Really appreciate you. Appreciate your time. For folks who want to connect with you, learn more about Motivo, where can they do so?

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Rachel Ledbetter (51:09):

Yeah, motivohealth.com is our website. I'm at rachel@motivohealth.com. That's R-A-C-H-E-L. And would love to talk to any of your listeners, and thank you, Michael, for the opportunity.

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Michael Fulwiler (51:20):

Thank you. Thanks for listening to this episode of Heard Business School, brought to you by Heard, the financial management platform for therapists. To get the class notes for this week's episode, go to joinheard.com/podcast. And don't forget to subscribe on YouTube, Apple, Spotify, or wherever you listen to podcasts. We'll see you in the next class.