5 Things I Learned the Hard Way in Starting a Private Practice

1) Ramping up too fast

When I started in my full-time private practice, I left my hospital social work job with no backup plan. For various reasons (including office space renovations that took longer and cost more than expected), I started operating from a “scarcity” mindset. I was afraid of running out of money and not getting enough clients.

I could have slowed down, but every time a client called, I was saying “yes” because I was afraid that might be the last inquiry I’d get, treating each referral like it was potentially my last. That led me to take on so many new people so quickly that it was really hard to stay organized or clinically and emotionally metabolize each new person.

THE RESULT: Feeling burnt out before I even got started.

2) Thinking I had to be the right therapist for every client and saying “yes” to everyone

Because I was coming from agency work, I wasn’t in the habit of thinking about whether clients were a good fit for my practice or not.

I didn’t think much about: “Who do I do my best work with? Where do I shine clinically?” I just took on who showed up.

Then I would scramble to try to take more trainings, read more books, do more supervision to try to feel like I knew what i was doing.

THE RESULT: Not feeling competent, not looking forward to going to work (because who wants to feel bad at their job?).

3) Not being organized from the start

Given all the rushing I was doing, it’s no surprise that I got behind on things. And given all my scarcity-based thinking, I put off paying for a good practice management system (like, Simple Practice).

Using Simple Practice from the start would have helped me take care of administrative things like intake paperwork, notes, billing, and tracking insurance payments way more easily.

I was trying to pinch pennies, but in reality, the time and emotional energy I could have saved would have been worth every penny.

I was caught in a cycle:

See clients all day → Work at hours I don’t want to be working → Feel exhausted at the end of the day → Tell myself that I will take care of all the things tomorrow → Not do it → Repeat

THE RESULT: Growing anxiety in knowing I had things piling up.

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4) Not sticking to (or even having a concept of) my office hours

Not only was I taking on clients too quickly, and clients that weren’t ideal for my particular practice, I was working hours that I didn’t want to work. I would ask people about their availability, and then find a time that suited them (versus the other way around!).

A consultant I was working with at the time said to me, “Melissa, do you ever call a doctor or a dentist and have them ask you ‘what time is good for you?’”

Ohhhhh right.

Why is it that as a therapist, it’s OK for me to scramble to meet client needs at the expense of my own when I wouldn’t expect someone from another profession to do the same?

It might feel like “it’s OK for me to take that 7pm client for XY or Z reason, even though it means [missing my favorite exercise class/not getting to put my kid to bed/pushing my evening routine back, causing me to go to bed late causing me to be tired the next day, etc].”

Over time, the effects of a seemingly small choice start to add up.

THE RESULT: Resentment, fatigue and burnout grow from pushing my own needs aside week after week.

5) Avoiding difficult conversations about money

So if you’re scoring at home, here’s what I’m feeling so far: fear, dread, incompetence, fatigue, burnout and budding resentment.

And at this point, I’m only about a year in. Yikes.

As my practice rolled along, I saw mostly insurance-based clients and a small handful of cash pay. I would say it was about 85/15 split percentage-wise. I realized that my business was not financially sustainable long-term with rent, training/supervision, and other expenses.

The bills were getting paid, and I had been putting away the minimum into a retirement account, but I couldn’t say too much more than that. I was going to have to make some changes. And the answer couldn’t be seeing more and more clients.

I would need to raise my fee and start moving off insurance panels.

I knew I had to make this change WELL before I actually did it. I let that part drag on for months out of fear.

I thought: “What if I go off insurance and I can’t get any self-pay clients? What if all my clients leave? What if I raise my fee and piss my clients off or hurt their feelings?”

THE RESULT: Stress, resentment, feeling stuck. Seeing my clients grow, change, go on vacations, and get promotions while I’m fretting about rent and chasing around payments from the insurance company.

So, how did I deal?

1) Starting to be honest about what I was feeling. First, with myself. I had to get past the shame (or put in a better way, take the shame along with me for the ride). I started talking about it to peers and consultants and in therapy.

2) Getting support (see above peers, consultants and therapy). Like actual support. People that were not just rooting for me (which is great) but were also asking me the tough questions.

3) Spending more time with people who were doing things the way I wanted to do them. Part of me hates that whole “you are the average of the five people you spend the most time with”. But, I do recognize that as social beings, a large part of our behavior is shaped by our peers and environment.

If you don’t have a community of other therapists or don’t know where to find the ones doing things differently, the good news is that there is so much available online if you don’t physically have access to a person who is doing something you aspire to because they probably have a podcast (or a YouTube channel, or a blog, or an Instagram).

4) Finding actual language. When it comes to having tough conversations with people, sometimes I just need some help with how to actually say the hard thing. How to word it, exactly. Once I get that part out of my mouth, I’m usually pretty good with the rest. So I would ask people, “What did you actually say?” and would literally write it down and practice it.

5) Doing the actual math!!! I put this off for a while, but once I actually did it, it was like the tell-tale heart beating under the floor that I couldn’t ignore for long.

I crunched my own numbers to figure out how much I was making per clinical hour and I realized that if I went off insurance, I would nearly double my income by working the same amount of hours.

My goal was not to make a million dollars (and no judgment here if that is your goal, go for it), it was to get my life back and not feel so exhausted all the time.

I realized I didn’t need that many full-fee clients to make that a reality! Once I realized that, it was hard to resist giving that to myself by making the switch.

6) Making some mindset shifts. A big mental struggle for me was “If I realize that a client is not a good fit, but I’ve already started seeing them, what do I do about that?” Even with the best screening, it certainly happens.

The mindset shift I had to make was two-fold:

a) Not everything can be your specialty, and you don’t do your best work with all people

b) By keeping a client you are not doing your best work with, you are not only doing yourself a disservice but also a disservice to the client by preventing them from finding a therapist who is the right fit.

For some of us, these two things can be hard to accept. I try to think about it this way:

Sure, basic therapy techniques are going to be helpful for most people. Who among us doesn’t gain something positive from empathic, reflective listening and undivided caring attention?

But if you think through your caseload and are honest with yourself, you will notice that there are some clients that you feel that sense of sparkle, magic, excitement, forward momentum- however you want to identify it!

It’s that thing that makes you look forward to going to work every day. Think about the good you are doing for yourself when you feel that and what a gift that is to your client. If you want to make this a lifelong career, that’s the feeling you need to follow.

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7) Slowing the eff down. I put a freeze on taking any new clients. I focused on doing good work with the ones I had and getting good supervision. I slowly worked at getting myself organized, setting goals for myself each week. And as some clients moved on, I didn’t refill the slots.

All the while, I started making a plan for when I would make the insurance panel jump. I also raised my fee for new clients, and had conversations with current self-pay clients about whether they could afford to increase their fee.

8) Doing some deeper work. Once I caught my breath, I was able to recognize that some of these issues ran a little deeper than circumstance. I was able to look more closely at how I got there, what I was enacting in all of this.

Final Thoughts

I hope reading this will give you some ideas about your own potential pitfalls, and how to deal with them. We all are going to make mistakes in business just as in life, and the best-case scenario is that we grow from them, learn, and to share what we know!

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