Category: Practice Management

Critical Tips for Building and Maintaining Your Private Practice: Avoiding Self-Defeat

Posted on by Psychotherapy.net Team

Over my consulting career with mental health professionals at various stages of their development, I have offered critical guidance about the development and maintenance of their private practices. I have also learned a great deal about why so many of them struggle in these efforts.

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All of us who see clients privately have likely heard stories about why some left treatment and came to us, or why they did not return to the former psychotherapist. In the process, we have also hopefully learned why we were chosen to be their therapist as opposed to others with whom they have consulted.

Successfully Managing Telephone Contact with Clients

There are many ways in which clinicians — often unknowingly — defeat their own interests in the course of building and maintaining their private practices. One of these is the difficulty managing and handling telephone contact with prospective clients. New clients who were given several names of therapists have reported to me that one of the reasons they came to see me was that I was the only one who returned their phone call, or that I returned their call on the same day, rather than two, three, or more days later. I am astonished every time I hear this.

Another familiar comment I’ve fielded surround concerns the “phone-side manner” of the therapist who does return the call: “Unfriendly,” “Cold,” “Abrupt,” “I felt like I was bothering them,” “Didn’t really seem to want to answer my questions,” “She sounded to me like I must sound to the salesperson who calls me at dinnertime,” and more. It seems that some therapists are not any more comfortable talking with strangers than prospective clients are comfortable talking with us.

Prospective clients who have been sent to us by a known referral source may simply be calling to make an appointment as instructed. For many others, however, that initial phone call is a fragile moment that may have been delayed for some time. This is a first opportunity to engage the client and establish a positive initial connection. Many prospective clients who feel uncomfortable or even put off during the first call will never make it to the first visit with that clinician. Some potential clients call to arrange an appointment and save their many questions for the first visit.

Other prospective clients, especially those who are ambivalent, fearful, or who are seeking help under duress, require answers to their questions on the phone before ever coming in for a session. How this conversation is handled by the therapist might well make the difference between a new client and a non-client. If a therapist is uncomfortable with a prospective client needing a lot of information during the first contact, it might be evident and affect the quality of the encounter. Some callers ask difficult questions that must be handled sensitively, e.g. “What is your fee?” “What is your orientation?” “How long will it take?” “Should I bring my spouse?” And my favorite: “Now that I’ve told you a little about my problem, do you think you can help me?”

Many therapists seem to struggle in answering questions about their fee. There is probably no really safe or “good” answer — at least on the phone, and especially for clients who have issues or conflicts about paying for psychotherapy. Some therapists try to dodge the question by saying that they do not discuss fees on the phone and attempt to postpone the fee discussion until the client agrees to come in. The caller may find this answer evasive and permanently end the encounter. With a direct answer, arguably a superior response, the therapist runs the risk of an abrupt end to the encounter. The prospective client may be comparison shopping and the stated fee may eliminate a therapist right away or the client may make an appointment and then not show up.

It is important to remember and utilize the “rules of engagement” we all learned many years ago. The first phone contact is, possibly, the beginning of treatment. It is essential that the clinician is attentive, receptive, steady, ready to be of service, and generous so that the person contemplating therapy feels recognized and accepted sympathetically as a person in trouble.

I have always conducted the first session as a courtesy, i.e., no fee. This, I believe, accomplishes a few ends. For one, it conveys that the possible treatment is not all about money — especially helpful to therapy “virgins” who have seen too many Woody Allen movies. Second, if, for whatever reason the relationship is not going forward, there is nothing owed for what will not be an ongoing experience; and third, if I choose not to accept an individual as a new client in my practice, they are relieved of having to pay to hear me decline and explain why.

The Importance of Client-Centered Office Space

Some therapists are not sufficiently mindful of the impact that their office — their physical space — has on their clients and what that space conveys, especially new clients. One client told me that the main reason she elected not to work with someone with whom she had consulted, “There was a large spring protruding from the couch I was invited to sit on. The couch was in terrible disrepair and so was I. I was afraid that the broken couch might be a metaphor of some kind, so I decided not to go back.” Another oft-heard complaint concerns inadequate soundproofing, and, in the case of some home offices, too many personal distractions that interfere with a sense of privacy and optimal concentration.

Some clients have spoken of their confusion and upset about not having been given clear instructions about how to locate the office and, once there, which door to enter, whether to ring the bell, and what to do when the therapist may be running late and does not immediately respond to their arrival. Sometimes the issues that we see as insignificant have a profound impact on our clients. If one agrees that a first session is often a particularly anxiety-arousing event with a more-than-likely vulnerable prospective client, then therapists should do everything possible to ensure that the journey from phone contact to first visit is as smooth and reassuring as possible.

The office bathroom can be another problem area. Client observations have included such things as broken toilets, no toilet paper, general hygienic neglect, and broken locks or no locks at all to ensure privacy. To some clients, some of these things may be hardly noticed, but to others, these moments have significant impact and may influence or determine their feelings about continuing the relationship itself. This is generally more of an issue with new clients. If one agrees that the therapeutic cathexis is likely to be to the office as well as the clinician, then appreciating the importance of an attractive, appealing, “holding (office) environment” is crucial.

Tips for Communicating with Referral Sources

One of the most common complaints I hear from those who consult with me for private practice help is that certain referral sources have stopped sending clients for reasons unclear or unknown. Curiously, some private practitioners resign themselves to the loss and quietly regret it without ever inquiring why.

Referral sources expect to be acknowledged and thanked when they send a client to your practice. They also like to be informed about the disposition of their referral and some appropriate and discreet information about how the person they sent to you is doing. When I was building my practice many years ago, I sent referral sources a one-page statement entitled, “My Treatment Approach,” (see addendum to this article) which enabled them to understand how I conduct the initial evaluation and what the client would be experiencing when they came to see me. Feedback over the years was quite positive. Some referral sources sent work my way citing this document as unlike anything they had ever received from a psychotherapist marketing a practice. I also sent referral sources articles that I had written, kept them abreast of changes to my practice. In this way, I maintained contact with them if they were considering sending a new client my way. When I have not received any referrals from a traditionally active referrer, I inquire why. Sometimes the answer is as simple as, “you just didn’t come to mind,” so my call or e-mail inquiry served to reestablish my presence.

How to Handle Termination

The problem for many clinicians here, it seems, is when a client announces a desire to end the treatment when they are ready, and their therapist is not. This is an unfortunately mishandled moment in many treatment relationships that often sours or ruptures the relationship — at times, irreparably. Some clinicians simply cannot let go and, rather than explore the client’s desire to terminate as the treatment issue it is, they wind up angrily challenging the client and becoming an adversary, rather than remaining a valuable ally. This sometimes leads to an abrupt severing of the relationship and the client will not return. He or she may seek a new therapist or, worse, may be reluctant to seek therapy again.

***

We are all very busy mental health professionals who, at times, run the risk of losing sight of the issues that have impact on our clients. Our interpersonal skills and sensitivity to client needs must go beyond the essence of the therapeutic contract. Attention to the areas of practice discussed above and the ways in which we represent ourselves has significant impact on the treatment and demonstrate respect and appreciation for the people in distress who have chosen to share their lives with us.

Addendum: My Treatment Approach

After making empathic contact, I conduct a mental status examination to arrive at as comprehensive an evaluation as possible in the initial hour. I assess motivation, capacity for insight, flexibility, frustration tolerance along with an understanding of the presenting problem and symptom constellation. I attempt to see how affects are handled, thoughts are presented, what mood is prevalent, and how well or poorly I am related to. Resistances are initially bypassed while attempting to ease the person into the therapeutic encounter.

I arrive at a psychotherapeutic diagnosis and develop a preliminary formulation of the goals of continued work. This formulation includes an understanding of what a person is seeking in his life and what seems to be blocking his or her progress and achievement. An informal “contract” is negotiated which serves as a blueprint for the therapeutic work ahead. There is early interpretation of the transference, where appropriate.

The above is done to determine whether interventive efforts should be directed at nurturing, maintaining, enhancing, or modifying inner capacities; mobilizing, improving, or changing environmental conditions; or improving the fit between inner capacities and external circumstances.

Questions for Thought and Discussion

Which of the author’s suggestions resonates most strongly with you? Not at all?

Which of his observations have you struggled with in your own practice development?

Identify three changes you can make to enhance your practice

Is Private Equity Coming for Your Therapy Practice? An Interview with Joe Bavonese

Posted on by rezendevknowfully.com

In Search of Golden Geese

Lawrence Rubin: You are a practicing psychotherapist, owner of a large group practice, and consultant to other practitioners around practice development — including selling those practices. You have also mentioned to me that you twice went through the full process of selling your own practice to private equity firms but changed your mind in each instance. What exactly is a private equity firm, and why the seeming current high level of interest in psychotherapy practices? 
Joe Bavonese:
private equity firms tend to be these rather large companies whose sole purpose is to buy other businesses as an investment and then flip them in a couple years
Private equity firms tend to be these rather large companies whose sole purpose is to buy other businesses as an investment and then flip them in a couple years, hopefully making a profit. In the last five years, they’ve figured out that mental health practices can be a very profitable company to purchase in lieu of trying to make a profit. So, we’ve seen this influx of these large national companies that are heavily funded who have either started their own practice — like BetterHelp — or are simply purchasing practices with the goal that “We’re going to buy maybe 5 or 10 practices and then in 3 years we’ll sell them all to a bigger fish and we’ll make 50 percent profit.”  
LR: If the sole purpose behind private equity firms buying practices is flipping and profiting from the sale, does it really benefit the owner of the practice beyond whatever remuneration they receive? Or perhaps what I’m asking is if there is any fidelity to the practice of psychotherapy involved in these purchases. 
JB: Well, that’s been the big controversy, Lawrence, because in the last few years, it seems like the larger the private equity firm and the more money they have, the less concerned they seem to be about patient care and/or how the staff is treated. So, that’s one of the ethical issues that I think a lot of practice owners are experiencing. You know, “Do I want to sell my practice to a company where the care of the clients may deteriorate, the staff may be unhappy, and I’ve nurtured this baby from day one as my legacy, and it’s all going to get trashed?” So, that’s definitely one of the big problems. 
LR: They say that you never really lose money buying real estate or gold, but why do these equity firms think that psychotherapy practices are golden geese, so to speak?  
JB:
what’s attractive about psychotherapy practices is that they are relatively inexpensive to run — you don’t need any fancy, expensive equipment
What’s attractive about psychotherapy practices is that they are relatively inexpensive to run — you don’t need any fancy, expensive equipment. The demand for mental health, especially since COVID, is through the roof. Then what they typically do is buy a practice that only has psychotherapists and immediately hire several psychiatrists which adds tremendously to the revenue and the profit margin. They’ll do things like this just to eke out as much profit as they can, but it’s really a volume game. In other words, they are really looking for large practices where there are 30, 40, or 50 therapists and then they can really show a higher profit margin on volume. 
LR: Is that common? Are there that many group practices of that size in this country to be bought? 
JB: Oh, yes. There are. I can talk in terms of revenue over size of the practice, but there are quite a few group practices that have revenue of at least $2 million. I know quite a few that are between $4 and $6 million gross revenue, and then the profit of that ranges from 15 to 25 percent. So, if you have a $5 million practice and you make a 20 percent profit, that’s a $1 million profit a year. That’s not chump change. 
LR: No. That’s not chump change at all. Is there a difference between a venture capital organization and a private equity firm when it comes to buying and selling psychotherapy practices? 
JB: I’ve not heard of a venture capital company wanting to buy a psychotherapy practice. You hear about how they seem to go after tech start-ups and things that really have a chance to scale tremendously. Psychotherapy doesn’t scale tremendously like a Facebook or Amazon.  
LR: What does scalability mean when it comes to selling and buying a private practice? 
JB:
over the last two years hiring has been very difficult
Scalability means you can grow exponentially. So, a typical experience would be that of a practice owner who has three therapists who says, “Wow, this is great. I’m making $1,000 profit a month for doing nothing.” Then suddenly, they have 6, 9, 12, 15, and 20 therapists, and they’re making $200,000/year profit, and it just grows rapidly exponentially. Almost everybody I know who has a large group practice never thought they’d get as big as they are. They’re always like, “Well, I thought I might get 5 or 10 therapists and have a nice little cushy cash flow on the side.” But once it takes off it’s almost like it just gathers momentum and more people hear about it. Now, having said that, over the last two years hiring has been very difficult. I think the pace of scalability and growth exponentially has slowed down for many practices. 

Winds of Change

LR: What factors contributed to the financial attractiveness and scalability of psychotherapy practices?  
JB: I started my group practice in 2000 and there was very little competition. So, it was relatively easy to find competent therapists who didn’t want to deal with their own office, didn’t want to deal with billing if they used insurance, didn’t want to deal with marketing or advertising. They just wanted to show up, do their work, and go home and not worry about anything else. That model worked for a lot of people, so I began coaching group practice owners. 

I designed a course called “Creating Group Practice” in 2009. Back then, almost everybody did very well. The harder thing was getting clients. Getting therapists seemed easier. During COVID, there were two things that kind of juxtaposed. There was COVID, and then there was the influx of private equity. So, we now have companies like BetterHelp that are — you’ve probably got these things in the mail — you know, a $500 signing bonus to do teletherapy.

There are more and more group practices. On Facebook, there’s a page called “The Group Practice Exchange.” It has like 3,000 members. There are more people who have realized that just having a solo practice may not provide enough money to live the lifestyle that they desire. That was certainly my motivation. I thought when I got out of grad school, “Oh, I just need to fill out my practice, my wife’s a therapist and there’s two of us, and we’ll be fine.” Well, life is expensive when you have kids, a retirement, college savings, and all that, and a lot of us realized it’s not enough money.  
LR: So, there was an exponential increase in group practices. Did COVID impact the scalability of practices and their value? 
JB:
as the interest rates have gone up along with fears of a recession the valuations that private equity firms have given group practice owners have gone down significantly
The peak valuations group practice owners were getting was around 2020. However, as the interest rates have gone up along with fears of a recession, the valuations that private equity firms have given group practice owners have gone down significantly. But in terms of your question, during COVID I think the virtual therapy businesses like Talkspace and BetterHelp, who had massive backup funding from Wall Street, just poured millions of dollars into hiring and advertising. So, that created a real problem. The other thing I’ve been hearing in the last six months from several group practice owners is that some of these companies are poaching their therapists. So, yes. It’s just created a whole different climate. Now, referrals are plentiful, although that seems to be slowing down a little lately. But finding therapists is much more difficult. 
LR: So, these trends are making private practices less attractive to equity firms right now, or more attractive? 
JB: Less. They’re willing to pay a lot less than they were just two years ago. The other trend I should mention, Lawrence, is that it’s never been easier for a therapist to go out on their own. I’ve heard so many cases over the last two years during COVID of good therapists leaving group practices saying, “I’m going to sit at home and do what we’re doing right now on Zoom or on some other platform, and I’m going to make 100 percent of the money, and I don’t need to pay for an office.”  
LR: So, there was a massive increase in interest in group practices, followed by decreased valuation related to COVID? 
JB: Yes, because the people that were able to hire during COVID did very well. I have several colleagues and friends who put a massive amount of money into hiring and retention. They hired recruiters and did all sorts of things. Many of them expanded tremendously during COVID because the referrals were plentiful, and it was just a matter of finding bodies and you could fill them up instantly with referrals. 
LR: Then that slowed down? 
JB: Yes. Group practice owners' ability to hire has been a problem. I was just talking to someone yesterday in Oregon. He has a large group practice and said, “The problem is that therapists are leaving to go on their own just to do teletherapy. No office payment. Plenty of referrals if they’re just on Psychology Today. And they’ve been able to keep 100 percent of the money.” 
LR:
but with COVID and the exodus into teletherapy these same therapists figured I don’t need to pay overhead anymore I can work in my pajamas out of my basement
So, the group therapy practices were a haven for therapists who didn’t want to run their own practices, but with COVID and the exodus into teletherapy, these same therapists figured, “I don’t need to pay overhead anymore. I can work in my pajamas out of my basement.” So, there’s been a retreat from group practices and the group practices became less profitable, scalable, and thus less interesting to private equity firms? 
JB: Yes. They’re still interested. It just seems like they are willing to pay less. There’s a concept when you value a practice called EBITDA, which stands for “earnings before interest, taxes, depreciation, and amortization.” But what it really means, to simplify it for our discussion today, is the profit of your business plus whatever you pay yourself that a buyer wouldn’t have to pay. So, for example, let’s say your practice value is $200,000 a year, but you pay yourself $50,000 a year for salary and you pay yourself $50,000 a year for healthcare and other miscellaneous personal expenses. Well, the new owner isn’t going to have to pay for either of those, so you add that to the $200,000 and now your valuation is suddenly $300,000. Then they give you a multiple of that as the ultimate value they’re willing to pay for the practice. Two years ago, people were getting multiples of 10 or 12 times their EBITDA. So, again, if it was $300,000, that could translate into a $3 million value. Now, in the last few months, I’m hearing 4 to 6 is typical, with occasionally an 8. So, the value you could get two years ago could be double what you get today. 

The Business of Practice Ownership

LR: It sounds like owning a group practice, or even a private practice, requires a certain degree of entrepreneurial skill. My understanding and my experience are that psychotherapists who are there to help others are not necessarily entrepreneurs. Do you find that that’s the case?  
JB:
one of the biggest struggles a lot of private practice owners have is separating the need for service from the need for paying attention to the bottom line, the numbers, and the money
Yes, absolutely. I’ve been coaching therapists since 2005. One of the biggest struggles a lot of private practice owners have is separating the need for service from the need for paying attention to the bottom line, the numbers, and the money. A lot of therapists tell me they feel guilty if they promote themselves. A lot of therapists are not good at numbers and keeping track of all the metrics. What I would say is the group practice owners who have succeeded at a high level are all entrepreneurial, have all studied business in various ways, and have figured out how to be a business owner as well as a clinician. 
LR: That makes sense. You certainly seem business savvy, so what was your experience like each time you went through the process of selling your practice but then pulled back? 
JB: It’s interesting. The first time I went through the process was in 2018. Valuations were still pretty low back then. But the process was that you got a letter saying, “This is what we’re willing to pay for your practice,” and then you have a 60-day period of due diligence where the company that wants to buy your practice wants to look at all your metrics to make sure that what you told them was accurate, which makes sense. So, if you said your revenue was $2 million and it was really $1 million, they would want to know that. So, you had to give them a slew of things like years of tax returns, profit and loss statements, and a lot of just busy work. A lot of spreadsheets, PDFs, and things like that.  

The part I found uncomfortable was that they basically try to prove that you’re lying to them. And you’re pretty much talking to a bean counter. You’re not talking to a therapist. So, their job is to prove that the numbers are valid and accurate. But my experience was they did it in a fairly demeaning way, which was uncomfortable. Like I said, “I gave you all these tax returns, all these bank statements, and you think I’m lying or hiding? What could I be hiding?” So, that was part of the process. Then what happens is that you start out with an offer and then their job is to whittle it down by saying fairly trivial things just to keep lowering the number, which can’t go up from the original number — but it can certainly go down. 
LR: Like car dealers. Just it’s not a car, it’s a practice. So, it was demeaning, it was patronizing, it was nickel and diming, and that sort of took the wind out of your sails? 
JB: Yes. Ultimately, we ended up with a number that I didn’t think was worth it because one of the things you think about is, well, how much profit do I make in a year? And if I could make up in two or three years what they were going to pay me in one lump sum, well, that seemed kind of stupid. I figured I could make a lot more money in 5 or 10 years than getting out now and just having this one lump sum. 
LR: It seems that the group practice owner contemplating a sale must consider not only financial issues, but lifestyle issues, existential issues, family issues. It’s not just a matter of how much money, but it’s what’s left for me professionally and financially if and when I do sell. 
JB: Yes, exactly. Because if I said to you, “I’m going to give you $3 million,” well, that sounds like a good chunk of money. 
LR: But? 
JB:
if you sell your practice and you leave, and you’ve devoted every waking second to this for the last 10 years, it’s a huge loss of meaning
But you’re going to pay taxes, you’re going to pay broker fees, you’re going to pay attorney fees. So, you usually end up with about two-thirds of that, and then is that enough money to live on for the rest of your life? In most cases, not. So, part of it is, do I have enough money to do this, or do I want to stay on and keep working like a lot of people do? I wasn’t interested in that when I was doing it, but a lot of people stay on once they sell and take an annual salary.

I’ve seen $125 to $250,000 a year, and that of course makes it easier to see if the money will last. But then you have the other issue of, “Now, I have a boss when I haven’t had a boss in years and I’m part of a large organization with politics and other things.” But you use the word existential. The meaning question I think is one of the significant ones because if you sell your practice and you leave, and you’ve devoted every waking second to this for the last 10 years, it’s a huge loss of meaning, and I don’t believe one that’s easily replaced. 
LR: What types of psychotherapy practices seem most attractive to private equity firms? 
JB: What they’re looking for is consistent growth over the last three years — 20 to 30 percent per year. They want to see an expansion in staff. They want to see diversification of services. They’d rather have a company that’s the one-stop-shop that deals with anxiety, depression, couples, and trauma rather than just somebody who has one specialty. They’re also interested to know if medication is prescribed by a nurse practitioner or psychiatrist, which is a huge bonus because it’s a cash cow for them. They’re also interested in geography — they want to enter a territory and start you as the hub of that territory. Or if they already have practices in your location, they may want to add you as one of the spokes around the hub. Those are some of the main factors that they’re looking for. Also, a healthy profit margin. If your profit margin is 8 percent instead of 20, well, you’re not going to get as much money because there’s an inefficiency there that they’re going to uncover. 
LR: Have sellers of group practices ever been held liable by these equity firms for unmet financial promises? “ 
JB: This is what happens. Usually, they structure the deal where they’ll say something like, “This is the price I’m willing to pay, but it’s contingent on a certain percentage of therapists staying,” because a certain percentage of therapists will typically leave after a sale. So, for example, what they’ll often do is they’ll say, “I’m going to pay you $1 million for the practice, but only $500,000 today, and then depending on the size of the staff in 6 or 12 months, I may only pay you $200,000 more because you’ve lost 20 percent of your staff.” So, it’s incumbent on the owner to be the cheerleader to encourage all the staff to stay on. Typically, they have better benefits than they had previously, so there are some incentives to stay on. But again, if the quality of the client care and the staff care decreases significantly, a lot of people are going to leave. 
LR: When a group practice owner is planning a sale, do they ask or have their therapists sign an “I will not leave” contract to protect themselves against that?  
JB:
almost every mental health stock in the last 2 years has gone down 70 or 80 percent
No. The company buying the practice will have a contract everybody must sign. They typically don’t tell them until the ninth inning. It might be two weeks before they close. So, all the therapists will usually meet with the group practice owner as well as somebody representing the buying company, and they’ll present them with a contract. Then they’ll say, “You have two weeks to sign this contract,” and if a significant number don’t sign it then the deal is off. So, that’s the tense part. I have known some deals where they didn’t have a thing like that. The other thing I should mention, Lawrence, is often the companies that are buying prefer that some of the compensation be in the form of stock options instead of cash. So, I might say to you, “Okay, I’m going to pay you $2 million, but $500,000 of that is going to be in stock options.” Then they’ll tout the potential of the stock. However, almost every mental health stock in the last 2 years has gone down 70 or 80 percent, so if you were one of the ones who were banking for a big payday because of your stock options you may have lost quite a bit of what you thought you were getting. 
LR: Stock options? 
JB: Yes. In other words, I’m a big company that’s on the stock exchange and I have shares that I will give you. I’m going to give you so many thousands of shares. But you can’t sell them right away. You’ve got to have two or three years before you can sell them. But remember, in the last two years, almost every mental health stock has gone down like the rest of the market. 
LR: So, when you’re saying mental health stock, you’re not talking mental health stock. You’re talking about the stocks and the shares in the private equity firms or the firms that own the firms? 
JB: Yes. 

Ethical Concerns and Red Flags

LR: You said one of the positives to the therapists who stay in the group practice are benefits. Maybe life insurance, certainly continued coverage of overhead. Are there any other benefits that the therapists who stay on reap as opposed to any disadvantages that accrue to the remaining therapists?  
JB:
the therapists who stay on are at the mercy of this rather large national company
The benefits usually include health insurance and retirement. Sometimes it includes stock options for the therapist. That’s another thing. The healthcare and the retirement stuff is generally better than what they had, but in terms of a downside to staying, it's that they’re suddenly part of a huge company instead of a tiny company with 30 or 40 employees, so the policies and procedures are often quite different. They have to learn how to use a new electronic medical record program. They might have to participate in more meetings. They have less say in changing anything, which they might have had at a group practice where they were able to meet with the owner and change something. Now, the therapists who stay on are at the mercy of this rather large national company. 

Sometimes what we’ve seen is that some of these large national companies really don’t have anybody who’s ever run a group practice at the higher levels. So, some of the things that they do don’t work very well. I’ll give you an example. A large national company may, for example, have five practices around Tampa and only one regional call center. A potential client can’t walk into the actual practice and make an appointment. They can’t walk into the office where their therapist works to speak with that therapist or check on their bill. They have to call this regional center that has no idea who they are. The feedback I hear is it’s been awful because people are used to getting answers right away with a friendly face in the office. There might be an office manager they can talk to. Suddenly, there’s this impersonal regional center that answers the calls and a lot of people don’t like that. 
LR: Along these lines, you mentioned that you’ve had serious concerns about the ethical issues of selling. This is obviously one of them — the stakeholder, the client getting lost in a large corporate machine. What other ethical concerns have arisen from this for both practitioners and clients? 
JB:
i think a lot of the ethical issues I hear are about the unknown part of the sale and how the staff will be treated
The other one is how the staff is treated. Again, when you run a group practice, you usually have a dedicated admin staff who have grown with you. It feels like your family. They’ve gone through all the tough times with you and the good times, so they’re very loyal. So, the idea of throwing these people to the wolves is part of the ethical issue. I think most group practice owners worry less about the therapists because there’s so many opportunities nowadays for them to land on their feet or go on their own. But I think a lot of the ethical issues I hear are about the unknown part of the sale and how the staff will be treated. For example, an owner may sell their practice in 2022, and the purchasing company says, “Yes, in 2025, we hope to sell out to another company and then all the policies and procedures are going to change again.” So, there’s this unknown. What am I subjecting my staff to? It’s just impossible to know. 
LR: Aside from the impersonal nature of practices that are regionally managed, are there other downsides? 
JB: In addition to feeling like things have gotten more impersonal and colder, there may be changes in insurance. There may be changes in therapists’ availability. There may be changes in non-competes. They may feel more locked into a schedule. Those are mostly the things that I think the clients or patients feel. 
LR: Are there any red or green flags when a group practice owner is sent a letter of interest by one of these national equity firms? 
JB:
in retrospect, I’m grateful I didn’t sell because I had no idea what I was doing
The group practice owner must do their own due diligence. In the last couple of years, most group practice owners of a significant size have gotten two to five letters like that in the mail. So, usually, they just want to talk to you on the phone initially and give you the sales pitch about why you should consider this. But I think the red flags would be you really need to be part of a support group of other group practice owners. I run or co-facilitate four different group practice online groups of various sizes and we share resources. Somebody said, “Oh, I’ve got a new one. I just got a letter today. Has anybody heard of this one?” So, it really helps, because when I first did this in 2018, I didn’t know anybody back then who had been approached or tried to sell so I was really shooting in the dark. In retrospect, I’m grateful I didn’t sell because I had no idea what I was doing. 
LR: What about when a single therapist gets a letter about joining a group practice that has been purchased? Any red flags there? Because I get several of these a week. 
JB: Again, you just have to do due diligence and see what they’re really offering and ask if it’s really any better than what you’re doing right now. You’re definitely going to lose some freedom. It may make certain aspects of your practice easier. But you really have to research. The companies are so different. Some of them seem very focused on clinical care, and with others it just seems like an afterthought, just as an example. 
LR: Have there been reports to the Better Business Bureau or to the APA, or are there similar places where someone while doing their due diligence could go to see if these private equity firms have not met their promise or been abusive? 
JB: As simple as this sounds, Lawrence, the best thing is often to go on Google and just type in the name of the company with the word reviews and it reveals quite a bit. Some of the companies are listed in the Better Business Bureau, though not all of them, and you can get some feedback there. But I’m just finding that the word of mouth through the community probably gives the best information. But I’m surprised by just how much you can get just from a simple Google search. 

A Short List of Tips

LR: Is there a short list of tips and guidance you could offer a practitioner who is approached by or seeks out a private equity firm?  
JB:
some of these equity firms not all are just ruthlessly focused on growth and all they care about is bigger bigger and bigger
Well, like I said, do your due diligence. Get as much information about the company as you can. Especially ask, “Why are you interested in my practice now? What is your goal for the next few years? What is your philosophy about how you treat the staff and the clients?” Because, like I said, some of these equity firms, not all, are just ruthlessly focused on growth and all they care about is bigger, bigger, and bigger, and it comes through clearly when you talk to them. Others will slow it down and talk about their philosophy. But you really want to zero in on how much do you really care about clinical care? How much do you care about the competence of the staff, or is it just a numbers game to you? So, those are some of the things you want to find out. 
LR: So, theoretically, a private equity firm could come in and just fire the whole staff? 
JB: Well, they wouldn’t do that because hiring even for them is still difficult these days. Really the only value of the whole enterprise is the staff and the client, so if you fired them, you’d lose the whole revenue. 
LR: In insurance companies there’s usually a psychologist who oversees claims and answers difficult questions. In your experience, has there been a clinical point person in these equity firms? 
JB: Yes. Usually, they have a clinical director, a regional clinical director, or a national one that you’ll talk to who will make everything sound sweet and rosy. But during that 60-day due diligence, that person is pretty absent and you’re mostly just talking to the accountants or the attorneys. 
LR: Boy, you’ve really got to be sharp and on your game. 
JB: Yes. That’s what I should mention. There’s no way as a licensed psychotherapist to do this on your own. You have to get a broker or some financial person to help you through it. It’s just too much stuff that you have no idea about. You need somebody who understands the lingo and can help you avoid the obvious traps. 
LR: Have private equity firms favored white-owned, white-serving practices? Is there a racial/cultural line? 
JB:
i would say the percentage of black owned group practices is lower than the percentage of Blacks in the population
That’s a good question. I would say the percentage of Black-owned group practices is lower than the percentage of Blacks in the population. Like I said, I’ve talked to probably 80 to 120 group practices in the last 5 years. It’s not an exhaustive search, but it probably gives me a fairly decent survey of who is out there. I haven’t heard of that. I think they’re more focused on the numbers and whether the location fits into their long-term strategy, but I really don’t have any data on that. 
LR: Of those 80-120 practices you’ve spoken with over the last 5 years, have you found that there’s a consensus around the right time to sell, or is it more idiosyncratic? 
JB: Well, it is idiosyncratic, but there are some categories I think people fall into. One category is that “I’m so burned out and sick of this, I’ve got to get out,” which unfortunately I know a fair number of people like that where they are constantly stressed out by their group practices, constantly stressed out, and physically and emotionally exhausted by the demands of dealing with the staff. For those people, I think if they can afford the deal financially, it is probably best to get out because they’re not happy. They’re really not enjoying the ride. Then the other thing is the category of people that just want to say, “I don’t want to ever have to work again if I can get a good enough deal, and if I like the philosophy of the company buying me, then that’s good and I’m happy to do it.” But again, it depends on your age, the age of your kids, all those financial things, and your lifestyle. So, I’m thinking the most common thing is that the motivation is financial, clearly. A good friend of mine recently said, “I’m looking for a new challenge. I’ve been doing this for 10 years. It works well, I know how to do it, but it’s getting kind of boring. And a lot of the private equity firms are saying, ‘I want to buy your practice and then I want you to spearhead the project of adding eight more locations around the area of your practice.’” 
LR: And they don’t want to do that. They just want the hell out. 
JB: Yes. But if they want to stay on to keep a salary coming, that’s basically what they’re going to be doing for a while. It’s just, “Okay, what do you think of this one?” More than likely, the parent company will fund it. One of the nice things people have told me is not having to worry about the price of furniture or computers — it’s sort of like a blank check. Whatever you need in terms of a new location, we’ll provide it. 
LR: So, the group practice owner who is ambivalent or who is not quite at the stage of life where they should make the decision probably needs to be coached? And that’s where you come in with your consulting service. 
JB:
i do one on one coaching. I have other colleagues who do one-on-one coaching for the same reason for those people
Yes. There are a lot of people who are interested in it, but they don’t know some of the things we’re talking about today. They don’t know the realities. Or somebody promised them something on the phone that turned out to be false in the long run. So, I do one-on-one coaching. I have other colleagues who do one-on-one coaching for the same reason for those people. 
LR: Joe, to turn the tables; if you were me interviewing you, is there anything I’ve missed? Any questions I could’ve asked that would deepen our readers’ understanding of the issues? 
JB: JB: I just think the existential issue gets minimalized by people. I really don’t think people realize how hard it is to replace meaning in their life because it’s not like most entrepreneurial-minded people who are successful at a group practice do not do well with free time. One of the phenomena I’ve seen which is interesting is that as people get bigger and more successful, they stop seeing clients totally and then they delegate more and more stuff, and suddenly they might only be working 10 or 20 hours a week. You would think on the surface that would be great, but what I hear is, “What do I do with my time?” So, it’s like having gaps in their schedule after working crazy hours for years to build this thing up is often difficult. It sounds funny, but it’s a real issue that I think people minimize when they go into this process. 
LR: So, I would imagine you often coach these folks around the existential issue, almost like doing therapy?  
JB:
one of the things that I did was to ask myself what were some of the things that I stopped doing when I had kids and when I started my group practice that I wished I could have continued
Yes. It becomes more therapy than business coaching at that point because everybody’s sense of meaning is different. But I guess it’s no different than retirement coaching other than they’re still working to some degree. But yes, it becomes more like therapy to kind of tease out, “Well, what are the most meaningful things?”

One of the things that I did was to ask myself, “What were some of the things that I stopped doing when I had kids and when I started my group practice that I wished I could have continued?” Then I made a list and that’s what I’m doing now, so it works out nicely. But I still think a lot of people have never thought about it. “Well, it’ll just be an endless vacation, or I’ll just play golf.”   
LR: Or climb mountains or go to baseball games. 
JB: That’s right. 
LR: Thanks so much for sharing your expertise and experience with me today, Joe. This area is so new to me, and I think it’s going to be equally new and hopefully helpful to many of our readers, some of whom may be contemplating joining a group practice or building a group practice or selling their group practice.  
JB: Well, good. I’m glad to hear that, thanks. 

5 Time Tested Methods for Attracting New Referrals and Building Your Brand

Posted on by Psychotherapy.net Team

Suggested Tips for Clinicians:

  • Learn SEO (search engine optimization) to bring foot traffic to your practice’s site.
  • Build your advertising savvy by mastering Google business tools.
  • Consider consulting with a business coach to build your clinical practice’s brand.
For most psychotherapists in private practice, the pattern of the past two and a half years has followed a similar trajectory:

March 2020: Move to 100% teletherapy, and watch as new referrals suddenly become frighteningly scarce.

April 2020: The phone is still not ringing.

May 2020: Referrals start coming back…and then explode. In the summer, waiting lists become commonplace because clinicians can’t handle all the people who need help during the pandemic that is killing thousands of people every month and forcing businesses and schools to go all virtual.  

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In 2020, Mental Health America reported that nearly 500,000 people struggled with a mental health disorder such as anxiety or depression. The organization offered online screenings from January through September, stating that anxiety screens increased by 634% while depression screens increased a staggering 873%. In just one year, the number of mental health visits attributed to new patients increased by 27 percent in July 2020 compared to July 2019.

The pandemic has deepened the mental health crisis, the report noted. The number of US adults expressing symptoms of major depressive disorder increased from 24 percent in August 2020 to 30 percent in December 2021, per CDC figures, and a recent article in the New York Times discussed the serious shortage in the US for child therapists.

As both an owner of a group practice as well as a business coach for psychotherapists and other group practices, I have had a birds-eye view of these patterns as they unfolded across North America. Many clinicians never had a waiting list before and were not sure how to process these inquiries. For some insurance-based group practices, the glut of referrals became a nightmare with waiting lists of over 100 people. Many potential clients were frustrated that no one in their city had any openings. Attempts to automate the process only created more feelings of depersonalization for clients and frustration for clinicians.

Yet despite these hardships, the pandemic also made marketing unnecessary for many private practices. It made it easier than ever before for licensed psychotherapists to go out on their own, working from home without even paying for an office. Spending $29.95/month for a Psychology Today ad was all that many practitioners needed to fill their schedules with new clients.

For group practices, the tricky balance of referrals, therapists and office space has been turned on its head by the pandemic. Referrals have been plentiful, but a significant number of sessions are still being conducted virtually, making decisions about future office space a guessing game. Availability of therapists has been the scarce resource of late, fueled by the sheer number of group practices and the deep advertising pockets of numerous online providers such as BetterHelp and TalkSpace.

But now there are signs that the glut of referrals is slowly diminishing for many private practitioners. As part of my business coaching service, I set up and maintain Google Ads campaigns for psychotherapists. The common refrain in the summer of 2020 was, “Turn the ads off! We can’t handle the inquiries we are getting!” That was great news because everyone could save a lot of money on marketing and still have plenty of referrals to fill caseloads. Suddenly, however, I have begun hearing the opposite from quite a few people: “Hey Joe, can you turn my ads back on? My waiting list is finally down to nothing.”

This trend is especially true for fee-for-service practices with rates over $200 per session. The combination of inflation, higher interest rates, and perceived easing of the pandemic may be leading more people to forgo therapy—especially expensive therapy—and return to other satisfying pre-pandemic activities such as indoor dining, music, travel, and visits with family and friends. Such activities may be serving as a natural antidepressant compared to the stark isolation and Zoom life during the peak of the pandemic.

So what’s a practitioner to do if a few holes suddenly appear in their caseload? As always, it’s wise to prepare for a storm when the first few clouds appear on the horizon. Interest rate increases and inflation are here to stay for a while, and fee-for-service providers are most at risk when consumers tighten their belts. To get ahead of these challenges, here are some of the time-tested methods for attracting new referrals:

     1. Improving Your Search Engine Optimization (SEO): Google is still the biggest source of referrals for most private practitioners, and nothing beats showing up on page one of Google for free. The bad news is that page one is more crowded than ever, and newer websites have a harder time competing against sites with years of immersion in the Google system. A good overview of best SEO practices you should follow can be found in numerous free resources online which can give you an idea of how to improve your ranking in Google’s search priority.

     2. Using Google Business Profile: Google still offers a wonderful free resource, the Business Profile, which includes a description of all your services, displays for photos and videos from your site, free messaging, opportunities to show up on the top half of page one with a Google Map link, and the ability to make free posts with links to your website. Note that managing individual Business Profiles will be moving to Search and Maps in the near future.

     3. Enabling Google Ads: This is still the best and easiest way to show up at the top of page one in Google search, but you’ll have to pay for the privilege. Recent improvements in automated bidding have reduced cost-per-click in many locations, and the ability to have potential clients call your office directly from an ad on their cell phone makes conversions easier than ever.

     4. Posting an Ad in Psychology Today: This grandparent of online directories for therapists still generates consistent referrals for many practitioners, and spending under $30 a month almost guarantees a positive return on investment even if you only get a few referrals a year.

     5. Community Networking: Now that more people are back in offices, marketing to referral sources in the community can offer a unique, inexpensive way to build a practice. Connect with medical professionals, educators, attorneys, and others who often need referrals for psychotherapists in their work.

     6. Creating Email Newsletters: Connecting (with permission) to past and present clients can be a wonderful way to get the word out about your services. Programs such as Constant Contact and MailChimp offer inexpensive ways to generate attractive email newsletters.

     7. Offering Lectures and Workshops: Offering lectures and workshops is a great way to attract people who may initially be resistant to psychotherapy. In my group practice, we have consistently found at least 20% of workshop attendees follow up with a therapy appointment. These can be offered in a variety of settings in the community, as well as in your own office if you have the space. And of course, if you can stomach it, you can also do them on Zoom.  

***

Attempting to read the tea leaves of psychotherapy practice is always a risky and imperfect task, especially in volatile times when unexpected events can quickly change the trajectory. Nonetheless, it seems clear that the peak of mental health referrals for some practitioners has passed. Preparing for this now will never hurt, and in fact will help to smooth out the transition if referrals drop to pre-pandemic levels.

 Questions for Thought

  • How did the pandemic challenge you to think differently about the way you practice?
  • What is your strategic short and long-term plan for building and maintaining referrals?
  • What can you do to revitalize your brand through internet marketing, pro bono workshops, and podcasts?
  • What is the feasibility of consulting with a marketing expert for you?
  • What about this article challenged you to do or think something differently to increase the client flow in your practice?  

Can Psychotherapy Really Survive the Onslaught of Venture Capitalism?

Posted on by Psychotherapy.net Team

Maybe you, like me, have been receiving solicitations inviting you to join various mental health platforms. Maybe you’ve seen online ads for these new companies with endorsements from the likes of Michael Phelps or Simone Biles and got curious about what they are offering potential clients. Or maybe, just maybe, you’re a dinosaur like me with an established private psychotherapy practice and thought none of this applies to you. In fact, there has been a huge influx of private equity funds into the world of mental health to the tune of over 2 billion dollars in 2020 (an increase from 275 million dollars in 2016) with the goal of changing how mental health services are delivered. Ignoring this reality risks an end for psychotherapy as we know it. Similar to the fate of the dinosaurs—it’s a moment of adaptation or extinction. When private equity funds target a market, it is because they see the potential for profit and growth. Analogous to the consolidation of hospitals and other health care services, the decentralized offering of most mental health services is ripe for the roll-up strategy used by investors to buy and build larger networks, thereby allowing them to wield more bargaining power with insurance companies and providers. Whether or not we realized it, many of us felt this change when insurance companies shrank the clinical hour from 50 minutes to 45 minutes, thus enabling providers to see 2 clients in 90 minutes. The existence of these mental health platforms creates many complex scenarios for clients and providers alike. After doing research and talking with providers who have worked for one of these companies, it is now clear to me that the lines between what is legal and what is ethical are blurred. What is also clear is that when the delivery of mental health changes, the “product” itself changes. We know people are struggling mightily to find mental health providers, especially those in rural areas or those who want to use their insurance. The pandemic only intensified a pre-existing problem of matching clients to clinicians. The ability to use telehealth and receive insurance reimbursement was certainly a godsend for many of us during the pandemic. In some cases, clinicians could even practice across state lines, opening up the potential for new client markets as well as allowing for continuation with clients who relocated. For many of us, this change was nearly seamless. But for the most part, we continued to function as individual providers. The thrust of telehealth platforms is to channel individual providers into what is ostensibly a virtual group practice. The owners of the practice—private equity or venture capital firms—benefit from amassing a large number of practitioners under one umbrella to help leverage reimbursement rates from insurance companies as well as set fees for prospective clients. The benefit for providers is not having to pay for office expenses, billing services, or marketing. But key questions remain as to who “owns” the clients, especially around issues of liability. The most obvious questions arise if a client commits suicide, but there are other important issues in this arena. From my research, there appears to be no consensus about how clients are vetted or if providers can take clients with them if they leave the company. One clinician I spoke with described a virtual speed dating-like service offered to potential clients. They received free 10-minute sessions with a number of clinicians to help them select a best-fit therapist. Other companies just match clients with clinicians who have availability. Some companies require a noncompete clause, in effect maintaining “ownership” of clients when clinicians leave. On the surface, none of these practices are illegal, but it is important to consider how these practices could easily be manipulated to become unethical. What is promised to clients about how treatment will be delivered? And, just as importantly, is this the kind of work that we signed up to do when we chose to become therapists? Adding to these concerns is the pay structure used for clinicians. Many of the companies have a matrix where reimbursement rates are higher if you see more clients. In addition, one practice owner I spoke with who was offered a buyout by one of these companies said that although the initial offer was well above market rate for his practice, the fine print made it clear that he would need to stay on as director and hit various target goals in order to realize his compensation. In the end, he recognized it was a case of “too good to be true.” Losing control of how many clients you need to see and discretion about which clients you will see raises serious ethical questions about quality of care delivered. It most certainly also goes to the heart of job satisfaction. If, as it appears to be, there is high burnout working for one of these companies, which leads to high turnover of clinicians, then what happens to the continuity of care for clients? And if providers’ reimbursement is linked to incentives that run the risk of reducing or compromising patient care, how can we avoid being in a potential conflict of interest? Sidestepping these changes by not joining one of these groups has consequences, too, as the marketplace changes. Individual providers or small group practices may not stay competitive with the reimbursement rates of larger groups in a geographical area. We need look no further than the changes that have come from the consolidation of insurance and hospital markets to see the array of problems that arise when the delivery of health care resides in the hands of MBAs rather than MDs. Despite the glaring fact that there is no clear evidence that consolidation actually improves quality of care, the trend toward changing the landscape for how people will receive mental health services is underway and it is worrisome. Health care has become a data-driven market, from the quantity of services provided to the choice of prescriptions offered. What happens to all the data that is collected? There is a lack of transparency about who owns patient data and how it will be used by companies to increase their profitability. The backbone of therapy is confidentiality, but how can we protect our clients from the accrual (and potential sharing) of data required by these companies? For this dinosaur, the transition to telehealth was an important and welcome adaptation to a pandemic. I benefited from being able to continue to work and not lose income. More recently I have adopted a hybrid practice, seeing clients either virtually or in person. Returning to in-person work reinforces my belief that for some people, telehealth is a poor substitute for the intangibles that come from sitting across from one another in an office. I think back to an earlier adaptation I made when I used to handle all my own billing, when life was simpler and Blue Cross/Blue Shield was basically the only game in town. Eventually, I decided that paying someone to do my billing was cost effective and certainly improved my own mental wellbeing. However, unlike what is happening through this influx of outside money today, none of these changes have threatened my autonomy as a clinician. I am in the twilight of my career and able to be selective about my caseload. It is easy for me to say that I would choose extinction rather than work for someone else. If, instead, I were just starting out, I am not sure how I would manage the current market trends for establishing a practice. But regardless of my individual choice, as a profession we need to be active and aware that simply locking the doors is not going to keep us safe from the real and present threats to the practice of therapy as we know it. Psychotherapy as a field has adapted over time from the early days when psychoanalysis was the mainstay of treatment to the present day when many theoretical orientations are available to clients. As our field confronts the inevitable forces of change, we need to remain vigilant that even if these changes are legal, that the ethics of our profession remain intact. For psychotherapy is an art as well as a science, and the essence of our work has always been about the relationship between provider and client.

***

I am grateful to Dr. Laura Feder and Dr. John Lusins for their time and insights on the questions raised in this essay. For further reading on this topic, I suggest: Mental Health, Meet Venture Capital (APA) The Toxic Impact of Venture Capital on Psychotherapy (AMHA) Venture Funding for Mental Health Startups Hits Record Highs as Anxiety, Depression Skyrockets (Forbes)

Money Matters in Therapy

Posted on by Psychotherapy.net Team

Money is often an emotion-laden topic that triggers many associations and meanings for both the therapist and the client. As a therapist starting out in private practice, I had to stumble and fumble my way around decisions regarding setting session fees, enforcing or waiving my cancellation fees and other money matters. I am sharing with you my lessons learned—and what better way to learn than from the mistakes I made.

Mistake #1: Adhering to theory or rules, even when it feels "wrong" (i.e., not aligned with my own personal values).

Something that is ingrained in us as therapists, especially for those of us who are trained psychoanalytically, is to "keep the frame" and "set boundaries." Stating and holding clear boundaries within the therapeutic relationship creates safety for the client. This could be translated rigidly into not negotiating around our fee, or enforcing cancellation policies by the rule. However, depending on the client’s situation and their personal history, this can actually backfire. It can negatively affect the client and the therapeutic relationship, especially if it is experienced by the client as punitive, shaming, unfair/exploitative or controlling. There must be some flexibility in all matters to accommodate therapists’ own values and clients’ needs, which translates into a willingness to reconsider session frequency, waiving cancellation fees, or negotiating around the fee on a case-by-case basis.

Mistake #2: Not examining and having clarity around my own issues with money/fees.

It is important to examine and have clarity on our own internal conflicts and issues around money matters, as well as to know the limits on our flexibility (e.g., what is the lowest fee that we will be comfortable with for a particular client and their situation?), especially when trying to establish boundaries and set a framework with a client.

I had to consider several conflicting needs and values when establishing my regular rate for therapy sessions. I do value my experience, training and what I have to offer as a psychotherapist, and a therapist with a higher fee is often perceived as offering “higher quality” services. At the same time, I think therapy is quite expensive, especially since weekly (or more frequent) sessions are usually recommended. People belonging to lower socio-economic classes face more stressors, therefore making it even more necessary to offer affordable mental health services. Despite my desire to make my services affordable and accessible, I have a strong aversion to being paneled with insurance companies. With so many competing values, initially I was often riddled with guilt, resentment or doubt as I tried to establish a fee that was “just right.” I have finally found a formula (using a combination of a regular rate, sliding scale fees and offering low fee and pro-bono slots via openpathcollective.org that works well for me, embodying the maxim “No size fits all.”

Scenario

What follows is a description of a scenario from when I was just starting out in private practice that highlights both Mistake #1 and Mistake #2 mentioned above:

The client and I agreed on a fee of $120 during the initial free consultation. At the end of the next session, the client told me she’d just found out that her insurance did not cover her sessions (she had a very high deductible) and asked for a reduced fee. Since we were already at the end of session (and keeping in mind that I had already provided her with a free initial consultation), I said that she had to pay $120 for this session, and that we could work out a lower fee moving forward. She asked for a fee of $80, and I said, “That is too low.” (yes, I have to admit that I actually said that). The client wrote a check for $120 for the first session and perhaps not unsurprisingly, did not return to therapy.

What played out in the above scenario were my own unresolved issues around money, and unfortunately these negatively impacted the client.

  • I was not completely okay with having provided her with an initial free consultation—I was holding some resentment, and thinking that the client now owed me or should feel obliged to me.
  • I was unsure about how low I could or should slide my fees. I was conflicted between what I had learned about enforcing boundaries, and my own instinct to be flexible in accepting lower fees. This resulted in me responding “That is too low” to the fee suggested by the client. This was shaming to my client, especially given her history of having grown up very poor.

Mistake #3: Not taking into account a client’s culture, history/background and relationship with money.

What I have seen replayed again and again, is that a client's relationship with money and how they approach the issue of the fee is often an extension of their psychology, and therefore, a clinical issue to be examined in therapy in order to help the client navigate more skillfully around such matters. Sometimes their relationship with money is shaped by culture—I have some clients who are bent on trying to negotiate a lower fee, although they have very high incomes—they cannot imagine paying so much “just” for therapy. Sometimes it is shaped by their personal history. I had another client who requested a lower fee due to her many medical expenses and I agreed, only to learn through the course of therapy that this client is a multimillionaire with an inherited fortune. Having grown up with financial scarcity and hardship, the client found it hard to spend or truly enjoy her newfound financial abundance, and she was always looking for a “good deal” or discount. If I, as the therapist, merely see such clients as “manipulative” or if I am offended by their requests and fail to consider the client's context and subjective experience, it is a signal for me to look into what is being triggered for me. I have learned that I must be mindful and navigate such issues around money with skill and sensitivity to the client's experience. In other words, letting the client know that I am open to discussing or negotiating the fee, but that it is important for me to first understand more of their history and their subjective experiences and relationship regarding having or not having things.

Guidelines

Below are my own personal guidelines around money matters in therapy:

  • Rules (such as charging for missed sessions) are set and enforced based on clinical implications and the client's best interest, and not merely based on business considerations.
  • Own my own issues (including privilege or scarcity) around money, examine my own relationship and views around money, and gain clarity on my limits in flexibility regarding session fees, cancellation policies and other money-related issues.
  • A client’s relationship with money (their meanings and associations around money, rather than simply their income or wealth) is an important factor to take into consideration when discussing and setting fees.
  • What works well for one therapist may not work for another. Differences may be due to business goals, theoretical orientation, populations served, and personal style/values.
  • Above all, be authentic.

I would like to end this article with a scenario that was posted on an online group for therapists that I participate in, that started me thinking more on this topic and prompted me to write this article. The scenario went as follows: If a person you were working with needed time off from therapy for a couple of months due to a short-term schedule conflict, but didn't want to lose their appointment space, and they offer to pay for that space until they were able to return (you have no other available appointments), is it ethical to accept that offer? The question elicited some emotionally charged but widely differing responses from the therapist group members. How would you handle this situation?

We’d love to hear your responses. Feel free to post to our facebook page here.  

Train Professionals, Not Just Therapists

Posted on by Psychotherapy.net Team

Becoming Professional

After hundreds of class hours learning systemic therapeutic modalities and hundreds more working directly with clients in multiple clinical settings, I graduated from my master’s program in marriage and family therapy a competent clinician. I treat couples, families and individuals on issues ranging from depression to trauma to affairs. But graduating clinicians is not enough—graduate programs have a responsibility not only to train clinicians but to help them become professional therapists. And that task is far more complex.

A professional therapist entering the workforce must learn to navigate the employment landscape, land a first job, determine long and short-term professional goals, understand the financial and professional implications of each of those steps, and build the tools to curate a digital presence that supports professional growth. A professional therapist must learn how to conceptualize the digital boundaries between therapist and client in an ever-transparent world and integrate HIPAA compliant technology. The professional therapist must understand the ins and outs of the insurance industry, at least enough to intelligently interact with it. These are the elements of the professional. And currently, most new therapists are running blind.

I consider myself fortunate. By the time I entered graduate school to become a marriage and family therapist, I had worked in corporate marketing, built a resume consulting business, traveled the world, and gotten married. In my second year of graduate school, I published a book that became an Amazon bestseller. I had also been fired from a good paying job and struggled through six months of unemployment and under-employment. When I started graduate school, I did so with eyes wide open. I researched the elements of building a career as a therapist, not just as a clinician. I read books about entrepreneurship. I began writing and trying to build an online presence. But even I, far better equipped than the average student, had so much to learn about building a professional future. Particularly for those students that transition from undergraduate to graduate school, the intricacies and big picture conceptualization of one’s career can feel overwhelming and most feel ill-equipped.

Jumping into a career as a therapist comes with an incredible level of uncertainty. A student leaving a master’s level program must decide whether to pursue a doctoral degree. Upon hearing other students speak about their intention to pursue a doctoral study, I asked them about that decision and what they envisioned for themselves. Many said they did not know, it was just “what was next.” The trajectory outside of academia remains unclear, and involves understanding how to work in a hospital setting, community mental health or private practice, and decide whether to pursue an inpatient or outpatient role.

Job hunting. Entrepreneurship. Business ownership. Accounting. Marketing. Digital boundaries. Online therapy. Working in hospital settings. Whose job is it to teach budding professionals to navigate this landscape with finesse, confidence, and an understanding of what’s required to succeed? I believe that graduate schools need to play a much larger role in not only training competent clinicians but also in preparing professional therapists to enter their careers. If a degree is marketed as a professional degree, then a student has a right to learn how to become a professional. Why don’t graduate schools teach students about more aspects of professional life? I suspect the answer is multi-faceted.

Not My Job

Some argue that professional training related to the non-clinical aspects of a therapist’s career falls outside of graduate schools’ purview. In other words, not my job. We figured it out and you will too. This line of argument, akin to a verbal shrug of the shoulders, a relinquishment of responsibility, fails to compel me. That programs have yet to step up does not mean they should not. I am a student of systems, and to create change that reverberates down the course of a therapist’s career, the initial steps must include the tools necessary to succeed in the world. We can do better.

Some argue that, well, they had to figure it out, and you will too. Sure, I suppose that argument rings true. “Every professional confronts a steep learning curve when they transition from school into the workplace”. But let us not fall into an all or nothing thinking trap here. Teaching new therapists how to plan out their career progression, how to understand insurance systems, how to manage student loans, and how to approach the task of entrepreneurship for many who want to build practices, will not eliminate the steep learning curve. I argue not that the student should be coddled, but rather, that they should be equipped.

Many therapists struggle to connect their work with money. Training as a clinician aligns with the selfless task of helping others, while money, marketing and business models feel like its necessary seedy underbelly. At the agency where I work, a sign on one clinician’s door reads, “I do it for the outcomes, not the income.” While the sentiment is a lovely one, it only reinforces the minimization and vilification of financial success, and unnecessarily puts success and therapeutic work at odds with one another. This thinking also exposes a misunderstanding of the professional therapist. The professional therapist does not sell to sell, they sell to serve. The therapist who can build a successful enterprise, who can reach their target clients effectively (be they kindergarteners struggling with grief or couples on the verge of divorce), who can walk confidently into an interview to work at a hospital or community mental health setting, is a therapist that can effectively help more people. What would our sector look like if new therapists were armed with an arsenal of tools, ideas and resources to help them spread their message more effectively and reach the clients who need them. This model of service reframes the issue as one of great responsibility, deeply in line with the therapist’s work. This is the framework needed when thinking about the business of therapy.

Harsh Realities

Perhaps another obstacle in the way of open communication around therapist career building is the stark economic realities it would force professional graduate programs to face. One imagines the discomfort it would cause to have professors, teaching in programs charging ten to sixty thousand dollars per year, openly discuss the financial reality of most early career therapists. Students who find full-time positions with benefits (scarce in the mental health arena), often struggle under the sheer weight of student loans.

Community mental health positions often come with a rude awakening of fee for service work, extremely low pay, high no-show rates, high incidences of client trauma, and overworked supervisors incapable of meeting the needs of their outpatient therapists. Launching and maintaining a private practice involves daunting start-up costs along with the often bewildering and complex tasks that accompany the effective marketing of the practice, renting or finding a space, learning about billing, purchasing malpractice insurance, ensuring HIPAA protected note storage, and accounting.

Indeed, many programs discourage students from jumping straight into private practice, believing in the growth potential and importance of working in community spaces. Perhaps the prospect of asking students buried under tens or hundreds of thousands of dollars in student debt to take a low paying job for the experience would be a tough sell, or at the very least, an awkward one. I wonder how it would go over for students to learn that professors in their fields either still have student debt or benefited from high-earning spouses who enabled them to work despite the early career steps. These conversations force still more difficult conversations about the access to education and the capital needed to get going.

Alas, the professors and teachers best equipped to imbue their students with clinical skills may feel or be the least equipped to prepare students to operate in the digital landscape. Clinicians with more than 20 years of clinical practice have at most a bare-bones website. Their digital footprint may be limited to Psychology Today. They may not be adept at utilizing modern marketing tools, lead generators, and using SEO technology to bring in more referrals through google and other search engines. They may not know how to manage mainstream social media and address the realities of increased online transparency that translates into the therapy room. Many did not come of age professionally in the digital area, navigating the public and private boundaries that are a constant challenge for new clinicians. New therapists require mentorship from clinicians who have been in the field from five to ten years to learn the trade in its most recent form.

At present, “there is little pressure for graduate programs to reconceptualize their role and implement sweeping changes”. Without pressure, schools are unlikely to change. Without a roadmap, schools would need to dedicate themselves wholeheartedly to the task and not only implement new measures, but also create them.

During my final year of graduate school, I and many of my classmates struggled not only under the weight of coursework, but the questions about what would happen after we graduated. Some of us wondered how to translate our clinical experience into a resume that would attract employers. Others wondered whether to prioritize the stability of a full-time job with benefits or the position that enabled us to work with our target population in a position without benefits. A panel discussion of past graduates inevitably led to sheepish questions by students wondering if graduates would be willing to get specific about just how much they earned and how secure they felt. Now as a recent graduate, settled into a semblance of routine, current students approach me with the same panoply of questions. Year to year, the emotions underlying these questions remain: fear, confusion, frustration, excitement, and bewilderment. Guide us, we beg over and over. Please.

What Now?

Therapeutic training programs are hardly alone in their failure to prepare professionals. Law schools notoriously work their students to the bone learning legal intricacies while failing to touch upon the actual experience of working as a lawyer. When my husband Brian compared his experience of medical school with my late grandfather’s almost sixty years ago, he received more practical training related to charting and taking patient histories. He even had a class called “doctoring.” But medical students, who navigate a siloed version of the economy through their extended training, often complete their residencies with no training in financial management (despite averaging almost two hundred thousand dollars in debt), no training in private practice building or planning, and little understanding of the way that the changing healthcare landscape will impact their careers. Programs training other service oriented professionals, accountants, contractors, architects, artists, and hair stylists must provide their students with at least a starter kit of tools to help them navigate the realities of their craft.

The culture of training mental health practitioners needs a comprehensive overhaul to integrate professional training into the process of becoming a clinician. Some programs attempt to address student needs by bringing in the student career center to offer little more than talking points on general resume tips. These fixes fail to address the larger structural deficiencies and fall short of the students’ needs. Professionalism, entrepreneurship, finances and the like should be woven into the content so that one’s professional identity is forming alongside one’s clinical identity. For this to take place, academia needs to make room for the reality of the marketplace, something it historically struggles to embrace.

In the meantime, the private sector has filled the void left by educational institutions. Blogs, social media groups and businesses tout services aimed at helping clinicians build practices, market themselves, curate their social media presence, and guide new graduates through the job hunt and licensure process. There is absolutely a role for this market and the solutions created are often comprehensive and built by professionals who have been through it already. As most things in therapy, the answer likely is not one or the other. We need both.
 

Changing Places

Posted on by Psychotherapy.net Team

The Nesting Instinct

Thirty years is a long time. When I started my psychotherapy practice as a newly-minted licensed psychologist in 1986, I didn’t expect to spend my entire career in one office. But the brownstone building and the location were great, and the space felt comfortable. The office was part of a suite with five offices, a shared waiting room and a bathroom. It was a large room with windows overlooking a tree-lined street. I never felt the desire to relocate my practice. Recently, however, the noise from new tenants in the apartment above my office became intolerable. The landlord was unwilling to intervene and clients were starting to look up at the ceiling due to the sound of a toddler jumping out of bed overhead. Additionally, the condition of the waiting room and bathroom had deteriorated. My frustration finally compelled me to start looking for new office space.

Although psychotherapy is about helping people realize change in their lives, personally I am often resistant to change. I love to travel and explore new things, but ever since my parents’ divorce when I was a young child, I developed a strong nesting instinct. Creating familiar and warm surroundings is core to my well-being. I will venture out into the unknown, but I like my surroundings to stay the same. “Moving is not something I do lightly”. During those same 30 years, I had moved homes twice, each time to accommodate a growing family. I was always grateful that my office stayed the same. It was the constant in my life, a proverbial “room of my own.”

There had been days when the comfort of my office extended to me as much as it did to my clients. Each time I was pregnant, I would nap on the couch whenever I had a free hour. The office was never cluttered with the accouterments of young children or the inevitable accumulation of “stuff.” Every night as I closed the door behind me, I knew I would find the office in the same condition the next day. The familiarity of the space was reassuring to me.

Time for Change

Therapists often admonish clients against “a geographical cure,” but sometimes relocation is the right decision. As I began looking for a new office, I knew I wanted to stay in the same neighborhood. Keeping my phone number and location was important to the stability of my practice. I was fortunate to find, just three city blocks away, an office with large windows and my own waiting room. The ceilings were higher and the building was non-residential. I signed a five-year lease, guaranteeing myself some permanence. I reassured myself that there were important lessons for me, as well as my clients, in this decision.

In the weeks leading up to the move, I was aware of feeling uncharacteristically unsure of myself. Finding a new parking space was challenging and I regularly forgot the code for the bathroom in the building as I checked the progress of the renovations in the new office. When I had the opportunity to meet the psychologist who was leaving the office, he reassured me that “The office has good karma.” He was retiring after 30 years and welcomed the opportunity to bequeath this important space in his life to another psychologist. He shared helpful insights about how the building worked and volunteered to introduce me to fellow therapists on the floor. His clear desire for me to be happy in the office eased some of my doubt about having made the right decision. The fact that he had had a successful practice in that space for thirty years seemed like a good omen.

It was critical for me to manage my own anxiety about unforeseen consequences of moving so that it would not be detrimental to my clients. Like all therapists, over the years I had weathered personal difficulties while continuing to work. During those times, I relied on a few trusted colleagues to support me. This time, through word of mouth, I sought out other therapists who had moved offices to learn from their experiences. It was enlightening to learn just how complicated most therapists find this decision. We all agreed that our attachment to our office was a by-product of our work. Opinions varied about how far in advance to tell clients about the move and whether or not it was important to bring anything from the old office to the new one. One colleague who had moved due to a fire in her old building, rather than by choice, spoke about how this trauma had been more than some of her clients could bear and consequently they did not follow her to her new office. Another colleague shared that after his move a few of his clients told him how uncomfortable they had found the previous office, something he had not been attuned to. In retrospect, he realized that his own comfort in the space had kept him from recognizing how dilapidated the surrounding neighborhood had become. These conversations, along with my own self-reflection, led me to wonder what was in store for me as I made my own move.

My Clients React

A therapist’s office reveals the personality of the therapist in subtle ways. Although family photos or other highly personal artifacts are typically absent, the color of the walls, the seating, and the artwork are chosen with care to convey safety and comfort. Indirectly, these choices do reveal something of our personalities to our clients. I had redecorated my old office a number of times over the years. Now, as I looked at the new space I was about to occupy, I wondered what to bring with me and what to replace. A complete makeover felt too unsettling. In the end, I decided I would paint the walls the same green I have loved for the past eight years and keep most of my furniture. I added an oak, two-drawer, lateral file cabinet and changed the artwork from Gauguin to Sargent. Having my own waiting room for the first time, I thought about how I wanted to present myself to potential new clients as well as my current caseload. It was exciting to have more control over my space. I doubt I would have felt comfortable in a professional office building at the start of my career, but now I was ready to leave the homey brownstone I was used to.

A month before my moving date, I informed my clients of the coming change. Relieved to learn I was not retiring, they had varied responses to the news of the relocation of my office. It was revealing to learn how deeply some of them were connected to the physical space, while for others the transition seemed seamless. One client enthusiastically said, “Where are we going?” Some were thrilled the new office would be closer to public transportation. Others talked about how much they loved the tree outside my window, and a few worried whether the new space would feel as comfortable as the one they knew. A couple of clients asked me directly what had led to my making this decision and when I shared my reasons about the noise from above and the general deterioration of the common space each one commented on how my decision to act made them feel cared for.

One long-time client, a woman who had a history of sexual abuse as a child, was very attached to my physical space. She revealed that, during many painful and uncomfortable hours of therapy, she had memorized the order of the books in my bookcase and counted the seashells on my windowsill when eye contact was too penetrating for her to bear. She took time to say goodbye to the office and to reflect on the hard work she had done over the years to voice her deepest fears. Her one request was that I put the books back on the bookshelf in exactly the same order.

One of the hardest truths for therapists is that we rarely get to hear the end of the story. On moving day I found myself overcome with an array of emotions, as I sat on the floor of my old office boxing up my files. Like long-forgotten photo albums dusted off only during a move, each file brought back the connection I had made with the person whose name it bore. There were some people I had seen for a single visit, but whose stories I had never forgotten. I’d known others for over twenty years. I grieved again the loss of someone’s son and the tragedy of a terminal illness. I calculated the current age of past clients and let myself wonder about them. Had he found love? Did she have children? There were clients for whom I was not a good match, a few who had left in anger. Reflecting on the depth of connections with clients past and present reminded me anew of why I love being a therapist.

Looking Back, Moving On

As I walked from my old office to the new one with boxes of files in my arms, I was aware that these were possessions too precious to leave to the movers. Of course, it is my duty to protect the privacy of my clients, but physically moving these files, my life’s work, over three trips, on my own, to their new home gave me confidence that this was a positive change. In a very real sense I was moving alone, but all the people I had known over the years were coming with me. I was no longer a brand-new therapist, but a seasoned professional eager to continue my work. Suddenly, the journey from my old office to my new one felt less like starting over and more like an affirmation that I was on the right path.

All of my clients chose to follow me which was a relief. I knew the move presented an opportunity for each of them to reflect on their commitment to therapy, and to me, at this point in time. For those where the connection between us felt more tentative, I was not sure if the disruption of the move would tip them toward terminating therapy. Other clients touched me by their vocal appreciation for my presence in their lives. A few even brought me “office warming” gifts and I was reminded that my ability to receive as well as give in my role as a therapist is helpful. I can model change, not just prescribe it. In fact, since the move, two of my clients who were unhappy with their living situations have made moves of their own. Perhaps this is mere coincidence, but I suspect not.

Change isn’t always for the better, but when it is, it is a great reminder that holding on for too long can be detrimental to growth. Initially, when faced with the need to move, I saw only the potential for loss. In fact, the opposite occurred. I am no longer distracted by unwelcome noise and the new space is beautiful. By listening to my feelings, but still taking action, I enhanced my own capacity to change. Undertaking this move at this stage of my career has reawakened in me the joy I felt starting my own psychotherapy practice so many years ago. The relocation of my office has affirmed for me the value of taking care of oneself. Unconsciously, I was overly attached to my old office and I failed to recognize that change could actually help me thrive. The insights I have gained from this experience will undoubtedly help me both professionally and personally.

Everyone loves the new office, particularly me. But the most important lesson I learned from changing places was summarized best by one my clients, “The office doesn’t make the therapist—the therapist makes the office.” After thirty years of practice, I have more confidence in what I offer my clients and I am looking forward to a vibrant next chapter in my career.
 

The Death of Privacy

Posted on by Psychotherapy.net Team
Nowhere is privacy more important than in the mental health field. We psychotherapists have always insisted on the highest standard of confidentiality for our patients. We want to be more protective than HIPPA and outdo the CIA in insisting on need-to-know. Even without the absolute protection the law gives attorney-client relationships, we resist whenever possible any intrusions from courts and from government investigators.

This effort has become even more important as privacy has disappeared from our society. People seem increasingly willing, even eager, to open their lives to public scrutiny through social media and other manifestations of the digital revolution. Texting, sexting, tweeting, personal blogging, online forums, and other displays of private, personal information are all too common, even when the consequences are employment problems, public shaming and legal jeopardy. Whether it’s loss of a job or a promotion, or revenge porn, or evidence in a criminal trial, the lesson never seems to be learned. If people want to be foolish in their personal lives, however, it’s their right to do so.

But nowadays many of us lose our privacy even when we want to protect it. Involuntary loss of privacy is increasingly prevalent as massive examples of hacking and the theft of personal information and identities destroys the attempt to keep private data private. Already, tens of millions of online medical records have fallen prey to malicious hackings. In our field, patients are routinely forced by third party payers to surrender their personal health data or lose their insurance coverage.

And now, a new and growing threat to the privacy of mental health information is the Electronic Health Record (EHR). With the government making the EHR a legal requirement, imposing fines for non-compliance and threatening to withhold reimbursement, the EHR is no longer a choice for many and soon might be universal. Even apparently benign uses of this data can lead to unauthorized disclosure when the EHR is shared with other providers, whether they be for medical, legal or justifiable mental health purposes. Once the information is out of our hands, we can no longer apply our standards to its release. The EHR represents a clear and present danger, but, unfortunately, it is also a legal document and cannot be entirely avoided.

The only remedy to this growing menace is to limit what we put into the EHR to the absolute necessary minimum. Examples are legally required data, such as the date of service, the next scheduled meeting, and any specific advice or prescribed treatment. We should also include any perceived risks, such as suicidal intent, and, most important, what steps we plan to take to mitigate them. Add perhaps any communications from other providers or significant sources of external information. In short, we are legally required to preserve any data that forms the basis for patient care.

We may also need to include the diagnosis, although that piece of data is the most problematic. Psychiatric diagnoses are simply observations that have been codified to facilitate communication and allow research comparisons. Nothing, however, embodies the stigma attached to mental illness more than a diagnostic label. In the EHR, available to all providers within the system and, through third party records, to anyone who ever provides care to that individual, it is likely to prejudice others against our patients and clients. Because it can bias the attitude of other caretakers, it may result in skewed, limited or even injurious treatment in the future. Where possible, we might use a brief description rather than a formal diagnosis. If that’s not feasible, then at least we can choose the least negative label available.

All the rest of what we’d like to memorialize—process notes, observations, plans, speculations and other insights—should be kept in a separate, non-digital record. Here is where paper is the best option. Paper can’t be hacked, won’t leave our control unless we want it to, and can be thoroughly and completely destroyed. No computer technician can retrieve the data from paper the way deleted material can be retrieved from a digital source. Paper can’t be squirreled away forever in a “cloud” server.

In our paper-based patient file—that only we ourselves will ever see—we can record anything that does not directly relate to patient care and that we would never want to release. After treatment ends, we can shred (or burn) the patient’s paper file and be confident we have protected both the patient’s privacy and our own standard of care.

The Secret to Getting More Therapy Referrals from Smartphone Users

Posted on by Psychotherapy.net Team

The shift from desktop/laptop computers to mobile devices—especially smartphones—has progressed faster than anyone predicted. In most parts of the United States, it is now typical for over 50% of searches for therapists to happen on iPhones or Android phones. Google itself admitted in May 2015 that there are now more searches on mobile than desktop/laptop computers. And while Google commands only about 67% of desktop/laptop searches, they control over 80% of searches on smartphones.

On the surface this would seem like a bad thing for private practitioners: a smaller screen that can only show a tiny part of your website; more distractions through nearby apps; and even shorter attention spans than on computers (around 8 seconds according to a recent Microsoft study). Does this make internet marketing, already a very competitive endeavor, even more difficult to succeed in?

Not necessarily. The fact that people are searching on a phone that knows its location, and can communicate easily with the outside world is an enormous opportunity to generate even more referrals to your practice. To take maximal advantage of this opportunity, you will need to do five things:

1) Take Google’s Mobile Friendly Test—Google will severely penalize websites that are not deemed “mobile friendly” by their free test.

Google wants to see a “responsive design” that automatically reformats based on the size of the screen. They also want to see buttons that are large enough for human fingers to touch and spaced far enough apart to not be confusing to the user.

2) Be Sure you Have a Verified Google Profile—go to www.google.com/business and be sure your business has been verified and is active in the Google system, and that your address and phone number are correct.

3) Add TEXTING as an Option to Contact You for Initial Inquiries—to take advantage of the fact that texting has become the preferred mode of communication for many people of all ages, be sure you offer this option for people looking for a therapist. If you don’t want to use a real cell phone number, simply get a free number in your area code to use exclusively for texting at Google Voice and configure the settings so you get an email every time someone texts you. And if they text you, call them back, do NOT text them back.

4) Be sure options for phone, texting and email are shown at the TOP of every mobile page. People do not scroll down mobile pages very far.

5) KEY ITEM: Make sure that ONE TOUCH is all it takes to initiate a phone call, text or email to you. No one will copy and type in your numbers or email address.

TWO BONUS ITEMS:

6) If you use Google AdWords, be sure you are using Call Extensions to enable people to call you directly from an ad.

7) Get rid of those cute Social Media icon links on your mobile pages. The last thing you want to do is invite someone to socialize when they finally get to your page. The chances of someone contacting you after going to the multiple distractions of Facebook is essentially zero.

Using exactly these items, I have been generating over 60 calls and 20 texts a month to my psychotherapy practice. We all would rather get phone calls to our office than visits to our website, and this is the exact formula to make that happen. And the trend toward mobile is only going to accelerate in the coming years. Take advantage of this opportunity now!

Lynn Grodzki on Building a Successful Private Practice

Posted on by Psychotherapy.net Team

Vocation vs. Occupation

Rachel Zoffness: Lynn Grodzki, you are a business consultant, therapist, and author, and you recently put out a second edition of your book, Building Your Ideal Private Practice. I’m really looking forward to learning from you today.
Lynn Grodzki: Thank you.
RZ: It’s an interesting challenge that therapists face when we finish grad school because we have so much training, and yet we know so little about the business side of things. Starting a private practice can be really overwhelming. When I passed my licensing exams, I was shocked by how hard it was to find even basic guidelines for how to start a private practice. I ended up meeting with mentors and friends in the field to try to find my way. What are your suggestions for therapists to shift into more of a business mindset when first beginning their practice?
LG: Well, first of all, I just want to validate your situation. When I was getting my graduate degree as a social worker, I also was surprised that they didn't include any information about practice development, and I found that that was pretty true of a lot of graduate programs.
A lot of therapists have never been trained in developing business plans, and so they end up just making do with whatever comes their way instead of planning and working toward pre-meditated goals.
I had been in small business prior to being a psychotherapist, so there was a lot about business that was familiar to me. I started out teaching classes and courses to therapists because I wanted to see them succeed, and as I worked with them over time, I saw that there were a few fundamental issues therapists faced right out of graduate school.

One is that they don’t seem to have an understanding of the difference between a vocation and an occupation. With an occupation, you really want to do things in a business-like way, but a lot of therapists see that as an affront to their idea of a vocation. It’s almost as if they’ll run their private practice as a hobby instead of a business.

An additional challenge is that a lot of therapists have never been trained in developing business plans, and so they end up just making do with whatever comes their way instead of planning and working toward pre-meditated goals.

RZ: What’s the best way to write a business plan, if you’ve never done it before, and you’ve never been to business school? Does every new therapist in private practice needs to hire a consultant?
LG: There’s lots of information out there, including my books and other books, so that you don’t have to hire anybody—you can read and get informed. But to have a business plan means that you have an idea of the kind of path that you want your practice to take. A really quick way to assess things is to think about your business strengths and limitations. In other words, what do you think you’re good at and what do you feel like might be limiting for you? You came out of a graduate program—what did you feel were business strengths that you might’ve just naturally had, and what were limitations you were aware of?
RZ: When I came out of grad school, I didn't even know what a business strength was. I wouldn’t even know how to put that into words for you.
LG: I often have a list of attributes that I feel are entrepreneurial skill sets. I’m going to talk you through a few of these, and I bet some of these really fit for you. Okay?
RZ: That would be so helpful.
LG: Entrepreneurial people who are successful, when they look at a situation, they often see opportunity. Therapists are very good at this, too—somebody comes into your office and tells you about their situation, and a lot of times, from your perspective, you see what’s possible. Would you say that that was a skill that you might have?
RZ: Absolutely.
LG: Here’s another one. Entrepreneurs have an equal measure of optimism and pragmatism, so they can see what might happen, and they can also be very concrete about the steps that they need to take. How would you do on that one?
RZ: I think I’m temperamentally pretty optimistic, but I don’t know that optimism would’ve been the best word to describe me when I was first starting my practice. I felt kind of bumbling, like I didn't really know what I was doing.
LG: So that would be one where you might think, “that’s one that I need a little bit of help with or I need more information about.” Here’s another one. Entrepreneurs are extremely persistent, and that means that if something doesn’t work, they don’t mind trying it, oh, another 100 times or so.
RZ: I think this is really a wonderful line of thinking because when I think about my strengths, having gone through two master’s degrees and a PhD program, that certainly took a lot of persistence. And here I am in private practice, and I do have my own business, and yet I’ve never even used the word “entrepreneur” to describe myself. I love that you’re using that word.
LG: It’s just a word that means that you own and operate a business. Here’s another one that’s very clear with people who succeed in business. They’re profit driven, and they enjoy making money. How would you say you feel about that one?

Money Issues

RZ: I think you’ve hit on something because I really struggle with the money aspect of my business, in part because I went into this field because I love helping kids. I’m a child psychologist, and I really struggle to set a fee that reflects my value, and part of that is because I worry that families won’t be able to afford my services if I charge more. I don’t want to be the kind of therapist who is thinking about money over people, but that is not a good business strategy. How do you help therapists establish that balance between being a therapist who’s really focused on people and relationships and being a business-minded person who’s focused on establishing a rate that’s fair but will still allow me to earn a decent income?
LG: One of the things that I do when I’m working with therapists is talk about the importance of understanding the negative belief systems they’ve developed about money. It’s very common and it’s not just therapists that have negative belief systems about money. It’s many people. It usually doesn't matter that much if you have these kinds of emotional issues about money, except when you own and operate a business because then it tends to get projected into the business.

I’ll give you an example. Let’s say you grew up in a family where there was a lot of financial deprivation, and you grew up hearing things like, “money doesn't grow on trees.” Or you grew up in a family where frugality was really prized, and that’s the way you live, and that’s the way you are, and it’s really not an issue for you until you start a business. In business, the mantra often is, “you have to spend money to make money,” and it’s really true. You cannot run a business on total frugality and be able to expand or take advantage of opportunities, and it even affects your relationships with colleagues if you're too frugal. They will find you cheap but not understand that it’s not a reflection of your skill set or the way you might be working with clients.

It’s just something about the way you grew up financially that says that you don’t have thank you cards that you send when you get a referral, or that you don’t believe in going to conferences, or something like that. One of the first steps I like therapists to do is to at least get some awareness about any of these negative money issues that might be playing into who they are and how they operate so that they can clear those up and start to look at this as a business.

The definition of a business is an entity that makes a profit, which takes us to another really key issue, which is that therapists need to reconcile profit versus service.

RZ: What do you mean by that?
LG:
Profit means financial gain, taking advantage of and moneymaking, and service means being of assistance, helping others, and benefiting the public. When you are in private practice, you’re doing both.
Profit means financial gain, taking advantage of and moneymaking, and service means being of assistance, helping others, and benefiting the public. When you are in private practice, you’re doing both. Because it’s a business, you need to make a profit, and because it’s your service that you’re offering, you have to hold true to the integrity, and the ethics, and the values of service, and you have to have a way to reconcile this inside yourself and in your practice.

Having a Niche

RZ: When I was first starting out, people kept telling me to have a niche. I am a cognitive behavioral therapist who works with kids and teens, and I thought that that was pretty specific, but I was also afraid of missing out on opportunities or potential clients. Now my practice focuses primarily on kids and teens who have chronic pain, and I’m starting to see why it’s so important to be able to be identified as a person who sees a specific population. In your eyes, what do you think are the pros and cons of establishing a niche?
LG: Well, from a marketing perspective, it’s really helpful to have a niche because there’s so much information that’s flooding everybody that if somebody can associate your practice with something specific, it makes your practice more memorable. So for marketing purposes, it’s a good strategy. In my book I talk about the therapy services that sell versus those that don’t, and one of the services that continually sells well are services for children because most parents will prioritize whatever kind of help their children need. In terms of the kind of practice that you develop, apart from marketing, chances are you can have a practice that’s more generalized over time if that’s what you prefer clinically. But from a marketing perspective, it’s still very useful to have a niche.
RZ: Do you think you can be pigeonholed by your referral sources if you end up marketing yourself as a therapist who just does one thing? What ends up happening if a couple years down the line you want to start seeing clients who have different presenting problems?
LG:
One of the services that continually sells well are services for children because most parents will prioritize whatever kind of help their children need.
Another marketing mantra is to be a big fish in a small pond. So rather than trying to reach out to everybody, it’s good to develop expertise and a reputation within a target audience, but that doesn't mean that you can’t have more than one target market. You could be a specialist in some kind of service for children, like doing CBT for some specific area for children. And let’s say, over time, you also wanted to become a couples therapist. You could certainly target another market, and your work with children would help their parents, so it would be a smart marketing move to make.

There’s nothing wrong with having more than one specialty area or more than one diversification in your business, but you want to do it in a planned way so that you are marketing and making the best use of your marketing dollars rather than just doing things based on anxiety.

RZ: Does that mean that every time you want to expand your practice and see a different population you need to rebrand and remarket yourself?
LG: You might. It depends how you approach your marketing. It’s not a cookie-cutter approach, where one size fits for all for all private practices and all therapists. It’s really customized.

There are hundreds of strategies of marketing that all work for different therapists, so the question is, how can you customize a marketing plan so that it works for you, so that you are always in your comfort zone when you’re marketing, so that the way you speak to other people, the way you advertise, the way you use your website, the kinds of activities you do are really comfortable and feel a lot like who you are?

RZ: What are just some basic marketing tips you would give to someone who’s just starting a practice?
LG: The first thing that you want to do is to develop your business identity. You want to have a website. You probably want to have a “Psychology Today” listing or some directory listing. You want to have a business card. You may want to have white papers. You might want to have a brochure. You want some materials that you’ve developed, and the great thing about taking the time to do that with some care is that it also gives you talking points.

We know from the data that we have that

50% of referrals these days are coming online to therapists.
50% of referrals these days are coming online to therapists. So you want to have your online presence be indicative and reflective of you at your best and what you feel like you have to offer. But you also then need to start to build community around your practice. You can’t just do it online—you need to network, to show up in places where you can have some collegial referral building and sharing with others. You need to learn how to talk about your work in a way that generates some referrals back to you.

The Tall Poppies

RZ: Marketing does seem to be a particular challenge for therapists. I find that it’s very hard for me to say nice things about myself, even though I know I’m supposed to highlight my strengths to attract clients. I’m even wary about telling about my extensive training, despite the fact that it’s relevant to potential clients, and they often want to hear about my training because it gives them faith about my skills and abilities. What would you say is a good way for therapists to talk about their strengths and their positive qualities without sounding arrogant?
LG: It’s interesting, I was giving presentations in Australia one year on practice building and talking about how to talk about your practice, and somebody raised their hand and said, “Well, we can’t do that over here, Lynn, because of the tall poppies.” I had never heard about the tall poppies in Australia.
RZ: Nor have I.
LG: The idea was that the tallest poppies in a field get cut down first, so you don’t want to stick your neck out or raise yourself above the others. You want to be modest. You want to be humble so that you don’t get cut down like a tall poppy. So in Australia, as well as with therapists, we have that same culture.

But it’s important to be able to share your enthusiasm and your passion for the work that you do. What’s most attractive when you’re talking with other people is the fact that you love your work, or find it interesting, or feel very good about what’s happening clinically. You want to have a way to talk about that normally and comfortably so that it sounds like you, in layperson’s language. If I was coaching you—and you’re a CBT therapist, right?

RZ: Yes.
LG: OK, let’s say you wanted to talk to people, maybe friends who have children, and it’s not that they or that their kids would be your clients but that they might become your referral sources once they understood what you did. So if somebody said to you, “Hey, Rachel, what’s new?” You might say one of the things that was new was that you were really enjoying your work these days or that you were seeing fascinating cases. That would be a great way to let somebody know the kind of work you do. And you’d want to be able to explain what CBT is in a phrase or two so that you don’t bog down the conversation.
RZ: So language is important. Word choice is important.
LG:
You want to have some talking points about who you are, what you do, and why you love what you do so that you could turn a normal conversation into a conversation about your work.
Language is important. One of the things I often say to people who are doing CBT is to use a phrase like, “These days, it’s the gold standard in talk therapy.” That’s something that a layperson or even somebody who might be an alternative healer, a massage therapist, a nutritionist, an occupational therapist might understand and remember. You want to have some talking points about who you are, what you do, and why you love what you do so that you could turn a normal conversation into a conversation about your work. That’s what business people do—they talk about their work. We want to be able to do that, too, when it’s appropriate as therapists.
RZ: I feel very lucky because I do love what I do, and I’m very passionate about it and energized by it, and I love the kids that I work with, but I’m wary of sounding like a walking advertisement. So what are some key components to having a good elevator pitch?
LG: I have a whole chapter on that in my book, and rather than an elevator pitch, I call it your “basic message.” It’s what’s true and basic about what you have to offer. You want to keep it short, you want to keep it filled with some enthusiasm or passion or interest so that you look good when you’re talking about it, and you just want to learn to love to say it, whatever it is. It can be what you specialize in and why you feel like it’s important. It could be some kind of a metaphor about the way that you work and how it works.

It’s not so much the words. It’s how you look and feel saying this that somebody’s going to remember. They’ll remember, “ahh, Dr. Zoffness was really passionate about her work. I bet she’s good at what she does.” You just want to find the right words that put a smile on your face or put a twinkle in your eye when you’re saying them.

RZ: That sounds very intuitive and very smart.
LG: And easier, right?

Your Ideal Client

RZ: I also noticed in your book that you talked a lot about finding your ideal client, which really resonated with me because, as I mentioned, I do a lot of chronic pain work with kids and teens, and at first it was really hard for me to find out how to find the kids that need me. I know they're out there, and I know I have the training to help them, but I wasn’t sure how to reach them. So I ended up walking into pediatricians’ offices with my CV and, more recently, I reached out to really smart doctors at UCSF and Stanford. Starting to build those relationships has helped me get in contact with those kids. What would you say is the best way of finding your ideal population, if you're just starting out?
LG: I like what you did a lot. You started to build a profile of who the children are that need your services and found a way to describe this child that really needs to see you so that a busy doctor in a hospital could remember this. One way to say that is, “Here’s the kind of child I’m best for,” and you describe it almost in bullet points. You know, a child who’s suffering from this kind of pain, a child who has this kind of capacity to use therapy, a child who is comfortable using their imagination or can write in a notebook. Whatever the things are that would help a doctor or another professional start to spot those kids that were right for you—that’s how you develop your ideal client.

You're doing the work for the referral source. You’ve already thought about this. You’re pulling together the words. You’re giving them the talking point so that they can take that message and say to a parent, “I have a psychologist that’s right for you because this psychologist is really good at working with kids just like your child.”

RZ: So finding the language that describes the kind of client you want to see and also finding the people who would know those kinds of clients.
LG: Yes. And this is what belongs on your website, and maybe in a brochure so that that after somebody meets you and talks to you, if they go back to your website, they see it repeated there, which gives people a sense of security and confidence.
RZ: It’s fairly easy for me, because of my personality, to reach out to people that I’ve never met before or to walk into a pediatrician’s office and introduce myself, but I know that that is not standard. What do you think is the best way to go about meeting other professionals, doctors, teachers, pediatricians, etc. for people who may have more difficulty networking with strangers?
LG: Well, these days, we know it’s hard to get past the front desk in doctors’ offices.
RZ: Yes, that’s true.
LG: So I have a couple different strategies that I like to recommend to therapists, and all of them are based on the idea of not doing a cold call. Even if you have a very small circle of acquaintances and friends, all of them know people that might be right for you to meet.

Even if you have a very small circle of acquaintances and friends, all of them know people that might be right for you to meet.
The challenge is writing the introductory letter or making the introductory phone call. You want to script it out if you're not comfortable just talking extemporaneously, so that you can say, “Hi, my name is Lynn Grodzki, and I’m a masters level clinical social worker in your area, and Joyce suggested that I talk to you because she knew that I had a certain skill set that she felt would be helpful for your patients. Can I set up a time to meet with you? Or I can also write to you if you prefer. What would be the best way for us to contact and connect with each other?”
RZ: So, the first step is communicating with your friends and colleagues, who you already have an established relationship with, and saying, “This is what I want to do. These are the people I’m looking for. I’m looking to grow my business.” And hopefully they connect you with other professionals who might be able to help you. And then, the next step is to email those professionals?
LG: Well, it depends. You have to find out. Sometimes you have to call a front desk or make an initial phone call to find out how would they like to get information from you, because everyone is different.

Another thing that I’ve had some therapists do who want more contact with doctors is, on their intake forms, have them get consent from patients and clients to connect with their health professional team so that they can start to set up an integrated healthcare process just by reaching out to those people who are treating their patients.

For example, let’s say there’s an internist, and you’re seeing their patient for depression. You get permission from the patient to contact the internist and then send a letter that goes into the file saying, “I wanted to introduce myself. I’m working with your patient. I’ve been given permission to contact you. I wanted you to know about the work that we’re doing together so that, if at any time in the future you have any concerns about this patient, you can connect with me and contact me, and we can speak.”

Imagine that this doctor is seeing the patient and all of the sudden feels uncomfortable at the level of anxiety or depression that this patient is showing. He’s already got a letter from the therapist in the file, with permission signed to contact them. That’s what happens in an integrated healthcare facility, except in this case you’ve initiated it on your own. At the same time, it’s giving you a great way to start to connect with other healthcare professionals who might remember you when they have a referral to make.

When Your Client Count is Down

RZ: Our business is unusual in that we can’t rely on having the same income from month to month because it depends on how many clients we have. In your book, you talk about living with that uncertainty. Can you talk a little bit about that?
LG: This is true in any small business. There is no guarantee, usually, about what your income is going to be month to month unless you have some kind of yearly contract that you're working under.
I strongly encourage therapists to be tracking their finances, to be tracking their client count, so that they can know what the ups and downs are in their business, and they can start to think about what they want to do to protect their income.
So for a private practice, you need to anticipate these ups and downs and have a way to both budget for them financially and also to deal with it emotionally so that when the business is down, you have a strategy for what to do. Then you kick into your marketing strategy when you start to notice that your client count is down. I strongly encourage therapists to be tracking their finances, to be tracking their client count, so that they can know what the ups and downs are in their business, and they can start to think about what they want to do to protect their income.

It’s not unusual, for example, for someone I’m coaching to say, “I’m down this month in my client count. Let’s talk about the things that I could do to reach out to people.” When this person is very full, they don’t have the time to do that kind of outreach, so we’ll have a plan ready for when they’ve got time on their schedule.

If you’re not tracking carefully, it’s really hard to do this, and it just lends itself to getting into a situation where you're really low with clients and then feeling really desperate.

RZ: What’s a good way to deal with the fact that there are going to be times where your business has a lull, and there are going to be times when your income isn’t what you want it to be or your client load isn’t what you want it to be?
LG: I think understanding the nature of private practice, that it just goes up and down, and having some self-care ways to calm your anxiety. Private practice really isn’t for everybody. There’s a 50% failure rate in small business, even now.
RZ: That’s significant.
LG: You have to have a thick skin and a strong inner core to ride out all the ups and downs, and that’s why some people decide “I don’t like this,” or “it’s too much work,” or “it requires business and marketing skills that I’m not comfortable with and I’d rather work for someone else.” That’s a fine decision to make, but if you are going to do this, you have to accept the whole package. There is a chance for a lot of autonomy and creativity and independence and profitability, but there is also uncertainty, some randomness, chaos, and you have to be able to structure yourself.

It’s Hard to Be Your Own Boss

RZ: I really like that you mentioned self-care, and I noticed that it’s really hard to be your own boss. I constantly find myself working when I should be resting or playing. How do you establish boundaries for yourself when you're in charge?
LG: Well, I live by my calendar. I really lean on the calendar. And if you were to look at my calendar, you would see self-care is in my calendar and my family time is in my calendar.
RZ: You literally schedule it in.
LG: