Thriving vs Surviving in Private Practice
The following is a summary of my Division 42 President’s address at the 2018 APA convention. If you would like a copy of the slide images, please contact me: firstname.lastname@example.org
“The news of my death has been greatly exaggerated.”
While Samuel Clemens (aka Mark Twain) didn’t say it quite that way (he actually said, “The report of my death is an exaggeration.”) the gist of this phrase is pertinent to private practice. For decades, naysayers have predicted the decline of private practice of psychology, but according to APA’s Center for Workforce Studies, almost half of US psychologists (45%) are in private practice (American Psychological Association, 2017).
Studies by Rupert and Morgan (2005), Walfish and Walraven (2005), Walfish and O’Donnell (2008), and other researchers show that clinicians in private practice enjoy their work and find it personally rewarding in terms of autonomy, intellectual stimulation, positive mental and physical health, and that they report experiencing less burnout than their colleagues in other work settings, to name a few advantages.
At the same time, the above researchers found that private practitioners reported high rates of dissatisfaction with their income and in dealing with managed care. This finding is consistent with what I read on listservs, and with what I hear at conferences and workshops.
With little in the way of business training, psychologists often enter private practice without much of a vision or plan. As long as the bills and living expenses are paid, private practitioners can survive.
But you can do better than survive. You can thrive. Thriving means working with people you most enjoy, in activities that you find most fulfilling, and getting paid enough to support your lifestyle and to fund your retirement.
Five steps to a thriving practice
- Know thyself.
Aristotle’s exhortation of 2400 years ago is still relevant today. Understanding yourself will help you create a practice that is a good fit for you. There are many ways to know yourself. Start by answering these questions:
- How would you describe yourself in 5 words?
- What inspired you to become a psychologist?
- What are your two favorite professional activities?
- If money were no object, how would you spend your time?
- In what situations or activities do you lose track of time?
In addition, check out the free VIA Character Survey at VIAcharacter.org, to learn about your strengths, which can inform your choice of work settings and activities that are likely to be fulfilling.
- Define the types of people you like working with.
You may be qualified to work with many types of people, but that doesn’t mean you have to take any and all referrals. In private practice, you can focus on working with those you enjoy most. That way, you will more often feel energized than drained.
Who are your ideal clients/patients? Think in terms of the types of people (i.e., demographics) and the types of problems or issues that you prefer to work with. These groups are your “target audiences.” Ideally, they will be people who need, want, and are able to pay for your services.
Next, make yourself visible to your target audiences and to referral sources who have access to them, such as physicians, attorneys and other professionals. Develop a marketing plan that includes community involvement and public education (writing and speaking about common psychological issues relevant to those you want to reach). That way, when someone needs mental health services, your name is likely to come to mind.
- Make peace with money!
Private practice is a business, and the goal of a business is to make a profit. But many clinicians have difficulty resolving their altruistic mindset with being well paid.
Several studies, including Trachtman (1999) and Britt et al. (2005) have addressed mental health professionals’ attitudes toward money. Many clinicians believe that it’s fine to earn “enough” money, but to earn a lot is deemed greedy and exploitive.
Some clinicians would further argue that we should only charge what people can afford. But “afford” is a subjective term. Most middle-class people will find a way to pay for what they want and value, such as restaurant meals, sporting events, vacations, electronics, furniture, birthday parties, Christmas gifts, alcohol, manicures, tattoos, and more.
When someone says “I can’t afford your fee,” it could mean that they are unable to pay. On the other hand, it could also mean that other things are more important, or that they don’t understand how your services will help them. In other words, they don’t value psychological treatment enough to make it a priority.
Lowering your fees won’t necessarily change their minds. In fact, it can it unintentionally reduce the perceived value of your services. Furthermore, with lower fees, your clinical effectiveness might suffer. If you need to work more hours to make ends meet, you put yourself at risk for fatigue and burnout, not to mention possible negative countertransference toward clients who seem financially better off than you.
The average course of therapy generally costs under $2000 out of pocket. That’s not a trivial amount, but it is within reach of people who will spend similar amounts on discretionary purchases–especially if they charge their sessions to a credit card and pay it off gradually. Other people may take out a loan or cut down on non-essential spending. For the truly indigent you can maintain a couple of free “scholarship” slots.
- Stand out from the competition
If you are in an area with a lot of mental health professionals, your practice will grow more quickly when people have a reason to choose you over your competitors. One way to stand out is to have a niche (a specific target audience such as young children, female executives, athletes, LGBTQ) or a specialty in treating specific types of problems. As you develop your reputation as a specialist, many people will pay higher fees to see you for treatment.
Another way to stand out is to offer conveniences or great customer service. For example, having Sunday office hours may appeal to individuals or families with busy mid-week schedules. Convenient location, free babysitting, and free parking help streamline the hassle of getting to one’s appointment. Do you speak a foreign language? Take credit cards? These are appreciated by certain groups of people. And don’t overlook the importance of a clean, comfortable and nice-smelling office.
- Think like an entrepreneur
Successful entrepreneurs notice opportunities that other people miss. They operationalize these opportunities into a business plan. They tolerate uncertainty and take action, knowing that there is some risk, but are prepared to deal with the downside. For more information on entrepreneurship see the work of Barringer and Ireland (2015) and Read et al. (2016).
As a psychologist, you can apply entrepreneurial thinking to use your skills outside the therapy room. For examples and inspiration, see the late Dr. Steve Walfish’s article in the Winter 2015 issue of The Independent Practitioner, “Growing and Sustaining a Private Practice: Opportunities Are Where You Find Them and Where You Make Them.” https://division42.org/wp-content/uploads/IPs/Winter-2015_IP.pdf
American Psychological Association, Center for Workforce Studies. (2017). Five recent findings about the psychology workforce. Retrieved from http://www.apa.org/workforce/presentations/2017-convention-handout.pdf
Barringer, B. & Ireland, D. (2015). Entrepreneurship: Successfully launching new ventures (5th ed.). Boston, MA: Pearson.
Britt, S. L., Klontz, B., Tibbetts, R., & Leitz, L. (2015). The financial health of mental health professionals. Journal of Financial Therapy, 6(1), 17-32. https://do i.org/10.4148/1944-9771.1076
Read, S., Sarasvathy, S., Dew, N., & Wiltbank, R. (2017). Effectual entrepreneurship (2nd ed.). New York: Routledge.
Rupert, P. A., & Morgan, D. J. (2005). Work setting and burnout among professional psychologists. Professional Psychology: Research and Practice, 36(5), 544-550.
Trachtman, R. (1999). The money taboo: Its effects in everyday life and in the practice of psychotherapy. Clinical Social Work Journal, 27, 275-288. https://doi.org/10.1023/A:1022842303387
Walfish, S. (2015, Winter). Growing and sustaining a private practice: Opportunities are where you find them and where you make them. Independent Practitioner: Bulletin of Psychologists of Independent Private Practice, 35(1), 24-28.
Walfish, S., & O’Donnell, P. (2008, Summer). Satisfaction and stresses in private practice. Independent Practitioner: Bulletin of Psychologists of Independent Private Practice, 28(3), 142.
Walfish, S., & Walraven, S. E. (2005). Career satisfaction of psychologists in independent practice. Counseling and Clinical Psychology Journal, 2(3), 124-133.
p.s. Division 42 welcomes new members.
Please encourage your colleagues to join at division42.org/membership.