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

My dear old friend Imposter Syndrome just loves to roll up on me any time I’m trying something new. It especially loves to creep in when I try something new and I’m not immediately amazing at it, and it’s not an overnight success (because yes, some internal script of mine tells me I should be good at things right away, and if I’m not, I should be embarrassed and not try, fun right?).

So I started to think about what I have to offer and what I actually kept coming back to were the things that didn’t go so well for me and how I dealt with them. Those things standout as the most valuable things I can offer to my readers and my clients.

I know that when I’m trying to learn something new, I especially love to hear about the mistakes and failures of those who have done what I’m attempting. Not because of some sort of schadenfreude, but because it gives me a clue as to where I might go wrong myself, and potentially some ways to avoid it.

So, with that in mind, here’s my list of all the biggest mistakes I made in private practice:

1) Ramping up too fast

When I first started in my full-time office I had left my agency job, with no back-up plan besides private practice. I intended to take the month of August off while renovations were being done, spend that time doing some marketing, building my new website, etc. All sounds great.

Except, the renovations took longer than expected. It was now nearing the end of September, and after a couple of months with no real income, and a bunch of money invested in getting the office up and ready, I started operating from a fear-based or “scarcity” mindset.

I was afraid of running out of money, and that I wouldn’t get enough clients.

My fears about money weren’t founded in reality. I had some savings to rely on that could have easily stretched my “runway”. And, in truth, the phone did keep ringing, and the emails kept rolling in. I easily could have slowed down, allowed myself time to metabolize the new referrals, and really screen for “goodness of fit” for the new referrals coming in.

But instead, every time a client called, I was pretty much saying “yes”, because I was afraid that might be the last inquiry I’d get, treating each referral like it was potentially my last. It lead to me taking on so many new people at once that it was really hard to stay organized, and clinically and emotionally metabolize each person.

The result: feeling burnt out before I even got started.

2) Taking clients that were not a good fit for my practice

Honestly, I think that because I was coming from agency work where I had to see everyone and anyone, I wasn’t in the habit of thinking about whether clients were a good fit for my practice or not.

I didn’t give much thought at the time about “who is my ideal client?” Nowadays, this is something I talk about to my consulting clients all the time. But my beliefs today are shaped by the experience of what it was like treating clients in my practice that weren’t a good match.

The result: Not feeling competent, not looking forward to going to work.

3) Not sticking to my office hours

Not only was I taking on clients too quickly, and poorly fit clients for my 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. I didn’t even really have a concept of office hours.

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?’“

Oh 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. etc. etc.” But over time, the effects of something small like that starts to add up.

The result: Resentments grow from pushing my own needs aside week after week.

4) 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 the fear-based, scarcity thinking I was doing, I put off paying for a good practice management system (for example Simple Practice) to help me take care of administrative things more easily because I was trying to pinch pennies, when in reality, the time and emotional energy it would have bought me back would have been worth every penny of the $40/month.

I wrote a whole article here about the benefits of when to start using a practice management system (hint: it’s right away).

But the main point here is that I got myself caught in a cycle:

See clients all day -> work more hours, or hours I don’t want to be working -> feel exhausted at the end of the day -> tell myself that I would take care of all the things tomorrow -> not do it. Repeat.

The result: Growing anxiety in knowing I had things piling up.

5) Avoiding difficult conversations about money

So if you’re scoring at home here’s what I’m feeling so far: fear, dread, incompetence, and budding resentment. And at this point I’m only about a year in.

As my practice rolled along, I realized that with rent in my area, business expenses, office expenses, and training and supervisions expenses, my fee structure was not financially sustainable long-term. I was seeing mostly insurance based clients from one insurance panel, and a small handful of cash pay. I would say it was about 85/15 split percentage-wise.

Here’s a version of Maslow’s Hierarchy of Needs created by Tiffany McLain of HeyTiffany.com that perfectly illustrates where I was:

I was hovering somewhere in the middle of this hierarchy. 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 long-term answer couldn’t be seeing more and more clients.

I was going to need to raise my fee, and start making moves to go off insurance. That will be the subject of a whole other post. But suffice to say, 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.

“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, get promotions, while I’m fretting about rent and chasing around payments from the insurance company.

So, how did I deal?

Here’s what helped:

1) Being 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), and then I started talking about it to peers and consultants and in therapy.

2) Support (see above peers, consultants and therapy). Like actual support. People that were not just about rooting for me (which is great) but 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 5 people you spend the most time with”. But, I do recognize that as social animals a large part of our behavior is actually shaped by our peers and our environment.

The good news is that these days there is so much available online if you don’t physically have access to a person who is doing something you aspire to, they probably have a podcast (or a YouTube channel, or a blog, or an Instagram). That has been a huge source of growth and inspiration. We don’t know that things can be different when we look around and see everyone doing them the same way.

4) Getting 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. Once I get that part out of my mouth, I’m usually pretty good with the rest. So I would ask people who have done what I wanted to do “What did you actually say?” and would literally write it down and practice it.

Going off insurance meme.jpg

5) DOING THE ACTUAL MATH!!! This is something that I put 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. 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, personally, was not to make a million dollars or anything (and no judgement here if that is your goal), but at that point it was to get my life back, get some balance again, 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 thing that I struggled with 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 my best screening, it certainly happens. The mindset shift I had to make was two-fold. The first part is not everything can be your specialty, and you don’t do your best work with all people and the second part is that by keeping a client you are not doing your best work with, you are not only doing yourself a disservice, but also doing a disservice to the client by keeping them from finding someone who is the right fit.

This can, for some of us, 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 about each client, if you 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 not only for yourself when you feel that, but what a gift that is to your client. If you want to make this a career that lasts a lifetime, that’s the feeling you want to follow

7) Slowing the eff down. I put a freeze on taking any new clients. I focused on getting to know 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 (and still am) able to look more closely at how I got there, what I was enacting in all of this.

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 share what we know.

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Melissa KellyComment