Counseling Today, Cover Stories

Establishing a private practice

By Laurie Meyers March 22, 2019

“If you build it, they will come.” Most of us are familiar with this popular misquote from the movie Field of Dreams (the actual quote is “he will come”), in which a ghostly voice urges Kevin Costner’s Iowa farmer to build a baseball diamond in his cornfield. Following through on this vision despite the risk of bankruptcy, Costner’s faith is eventually rewarded when he gets the chance to reconcile with his deceased father and multitudes of fans start flocking to his “field of dreams” to watch baseball games.

It’s an attractive and enchanting thought: Give the people what they want (or need), pursue your dreams, and the rest will follow. However …

Remember the dream part? In real life, establishing a small business such as a private counseling practice requires a lot of preparation, planning and ongoing maintenance. Being a good clinician is not enough. Counselors who have established their own practices say that the other major requirement for success is business skill — and more of it than many of them expected they would need.

How will you market your practice? Who will do the scheduling and billing? File the paperwork? Balance the books? These are just a few of the questions counselors need to consider as they contemplate establishing a private practice.

Counseling Today asked four American Counseling Association members with experience in private practice to share their stories, their lessons learned and tips for others in the profession who might be looking to strike out on their own.

 

Tapping into the power of the internet

Ryan Thomas Neace, a licensed professional counselor (LPC) and founder of Change Inc., a private practice located in St. Louis, first discovered his entrepreneurial spirit when he established himself as a local DJ at age 15. Neace started working in entry-level mental health positions during his first year of graduate school, and over the course of eight years gained experience in residential, agency, school, in-home, college and community counseling. Along the way, he discovered something crucial: He was an excellent clinician but a terrible employee.

“I tended to do first and ask forgiveness later, whether or not it coincided with what I thought management might want, because I typically thought my ideas were better and less bound to inside-the-box thinking,” Neace says. “I was right, I think, but it wasn’t a very good way to
stay employed.”

Fortunately, Neace’s entrepreneurial spirit and good connections put him on the path to self-employment. “In the course of all of that action [working in numerous counseling environments], I had latched on to a mentor who saw a lot of promise in me and recognized I was gifted in some ways he was not — business acumen, administration, etc. — and he asked me whether I’d consider starting a private practice with him in Virginia. We started brainstorming, and that was that. He put up about $10,000 for office furniture and technology, and we found the space we liked.”

Neace and his mentor co-owned and ran the practice together for several years, but, eventually, both wanted to move to different areas of the country. “I moved back to St. Louis in 2013 and started my first sole ownership practice there,” Neace says. “Five years later, it has two locations, 12 therapists, several support staff, and we’re conducting approximately 700 client sessions per month.”

Although Neace’s move was obviously a success, he acknowledges that it took a substantial amount of hard work and planning to achieve. “About 18 months before I moved back to St. Louis, I started looking online at where all of the counseling practices were,” he says. “I noticed that there tended to be a large accumulation of practices in the western county parts of the metropolitan area but not a ton in the up-and-coming urban areas that for several years were being revitalized and developed. While the county regions were clearly where a majority of the local wealth was, I decided that if I priced our services effectively, there was a decided advantage to being more local to the city itself. We could pick up [gain] residents who were tired of driving to the county for mental health services, and we could even get county residents who were dissatisfied with the kinds of therapists who dominated the landscape in their neck of the woods or [those residents] who worked in the city and might find the idea of getting therapy in the city attractive from a convenience standpoint — [for example] on their lunch hour — or from the perspective of having a bit of geographic distance between themselves and their therapist’s location.”

During this period of research, Neace was also building a website for his practice on WordPress. He already had some experience working with websites, and anything that he didn’t know, he found through online tutorials or support forums. Recognizing that the most essential part of having an online presence is showing up in search results, Neace sought help from a friend who was an expert in search engine optimization (SEO).

The friend taught Neace how to ensure that Change Inc. would show up whenever someone searched online for terms such as “St. Louis____ (anxiety, depression, LGBTQ, etc.) counseling.” Three to six months before Neace was even scheduled to make the move to St. Louis, he was already getting one to two phone calls per week from prospective clients. One month before Neace opened the doors to his new practice, he already had his first few clients scheduled.

Today, Neace’s practice continues to focus on SEO even as it has developed a stream of referrals from previous clients and area clinicians with whom Neace has built relationships. Change Inc. has also taken a nontraditional approach to marketing.

“Instead of spending money on traditional print or other marketing efforts, we partner with other small businesses — typically nonprofits — that have a mission we feel is supportive of our own and that reach a target demographic similar to our own,” Neace says. “We offer these organizations financial support in exchange for direct marketing opportunities to their target audiences and brand association, [such as] event or web advertising where our brand and their brand is featured together in a prominent way.”

Neace acknowledges that owning his own practice can be demanding, but for him, it produces less anxiety than trying to work within someone else’s confines. “Certainly, owning a practice increases the stress, though I think it’s a qualitatively different kind of stress,” he says. “Perhaps the most prominent difficulty in ownership for me is the heightening of my personal sense of loneliness, in that no one sees how much I’ve risked or how hard it can be, simply by virtue of the fact that they aren’t owners. But if you’re an entrepreneur of my kind, it is a labor of love where the rewards far outweigh the additional stress.

“Again, I’m highly motivated by the autonomy and independent decision-making, as well as the notion that each decision I make stands to increase my interests financially and otherwise. And I love getting to create an environment that prioritizes the elements of counseling that I believe are most important to transformational clinical work.”

When asked what advice he would give to counselors interested in setting up their own practices, Neace emphasized the following:

  • “Learn and implement SEO like your life depends on it. People should be able to search ‘Your city, Your industry, _____’ and you come up in the top five every time.”
  • “Find someone you trust who has a business that is thriving and ask them every question [you have]. Trust that if you are annoying them or if they don’t want to answer, they will tell you. Otherwise, be totally relentless about learning from them.”
  • “Remember that most people selling business how-tos are actually in the business of selling business how-tos, not in the business of having a successful, meaningful business. Most of the good information is free [from] mentors/friends … or next to free [from] books.” (Neace particularly recommends The E-Myth Revisited: Why Most Small Businesses Don’t Work and What to Do About It, by Michael Gerber, and Built to Sell: Building a Business That Can Thrive Without You, by John Warrillow.)
  • “Don’t be bogged down by convention. Do it the way you want to unless it absolutely makes no [financial] sense. Expect that people will tell you you’re breaking the rules and to generally be appalled that you have the audacity to think outside the box.”
  • “When you get scared and want to quit, run the numbers. Calculate the amount of money you need to keep the business afloat each month, and let that be your true north.”
  • “It helped that I had a side hustle [adjunct teaching online]. On the other hand, eventually it will eat into your ability to do the business. There’s definitely something to being all-in. If you keep a side hustle, keep one that doesn’t give you enough to live on. Let the hunger you feel drive you.”
  • “Don’t try to have everything at once. For the first two years, I worked in a space with old carpet and paint, three empty offices and a waiting room with the couch from my basement and some chairs I bought off Craigslist. Rome wasn’t built in a day.”

 

Knowing your strengths and maintaining flexibility

“In my 25 years as a therapist, I’ve been in and out of private practice depending on the needs of myself and my family,” explains Keri Riggs, an LPC currently practicing full time in the Dallas area. “So, I’ve worked full time as executive director of a nonprofit and full time as an intensive outpatient coordinator at a hospital. I always wanted to keep my hand in counseling, so I often contracted through agencies or under other therapists or had a solo practice while still being employed.”

“I believe when counselors are just starting out, the decision about solo practice depends a great deal on their economic or marital status,” Riggs says. “If you have a stable family income with benefits, your options are different than if you are a single parent or sole income provider for your household.”

Riggs cautions others to think carefully about giving up additional sources of income while building a practice. “I … regretted quitting my part-time agency work while building my practice. I only made $17,000 that year, and it was the toughest year ever,” she says.

Riggs has used a variety of methods to attract clients. “I see many resources on Facebook or online promising people can have a flourishing full-pay, noninsurance practice within a year, but that hasn’t been my experience,” she says. “I believe it depends on demand in the geographical area [and whether] a counselor elects to accept insurance or employee assistance program work.”

In Riggs’ experience, it usually takes two to three years to build a full practice. “I do believe it’s valuable to network and to have a niche but also not to over-focus on that,” she says.

However, Riggs does recommends that counselors focus their marketing efforts. “Don’t just send flyers to doctors’ offices. They end up in the trash before a doctor ever sees them,” she says. Instead, she advises that private practitioners find ways to speak directly to their target client populations, such as by holding workshops or giving presentations at service organizations.

Riggs enjoys running her own practice but grants that being a CEO and a counselor is a tough balancing act. “There’s a saying: You can’t work on the business when you’re working in the business. So, if I’m seeing clients, I can’t be working on marketing, billing/accounting, networking, blogging.”

In addition to seeing clients and running the business side of things, it’s essential that self-employed counselors continue to devote time to self-care, Riggs says. “I’ve discovered my magic number of clients I can see in a row and in a day,” she says. “I’ve blocked time in my calendar as I’ve gotten busier to eat, return phone calls and do administrative tasks. Occasionally, I block a mental health day for myself and spend time with non-therapist friends.” Peer consultation is also essential, Riggs adds.

Riggs doesn’t have office support staff but does outsource certain tasks. She employs an accountant and someone to manage her website and consults with a social media expert. She does her own scheduling, billing and filing of health insurance claims with a little technological assistance. Riggs uses practice management software that allows clients to schedule online, sends clients appointment reminders, bills insurance, posts payments and even provides a central place for Riggs to take progress notes and write treatment plans. “I couldn’t manage without it,” she says.

Not having the luxury of sick time or paid leave as a private practitioner can be difficult, but Riggs thinks the trade-off is worth it. “I love the freedom and I love being my own boss,” she says. “I can arrange to go to the kids’ school or doctors’ appointments or even take a recharge nap on my office couch in between clients if I need to.”

When asked what advice she would give to counselors interested in setting up their own practices, Riggs says the following:

  • “Work with your own personality strengths and weaknesses. If you procrastinate on accounting and hate it but have a talent for writing, spend your time writing and hire someone to help with the financial aspects.”
  • “If you don’t want to deal with the administrative aspects of your practice, don’t. Get with a group [that] provides that for you and willingly pay the costs involved.”
  • “Don’t feel like you have to do everything all at once. Serve the clients you have and serve them well.”
  • “Find a supportive accountability partner if needed, and engage in regular peer consultation with other counselors.”
  • “Be kind to yourself. Keep learning and growing.”
  • “Make sure you have a life outside of work.”

 

Identifying a need and growing into a group practice

Michael Stokes, an LPC and founder of Stokes Counseling Services LLC, in Naugatuck, Connecticut, set up his own practice because he wanted to develop a niche devoted to treating LGBTQ individuals and their families. “There were not agencies focused on LGBTQ services in my area, and this was a significant unmet need in my community,” he explains.

To get up and running, Stokes networked with other counselors in private practice, but he says he owes the most to a former supervisor. “Her guidance around logistics helped me develop a step-by-step process for opening my practice. The first step was finding an office location [and] community I wanted to practice in. This was not difficult since I knew exactly the town where I wanted to set up my practice. From there, I needed to find office space I could afford. Living paycheck to paycheck, I needed something extremely cheap. I cashed in my saving bonds from when I was a baby and used that $500 to secure my lease on the office space. After the office space, I finalized my paperwork [and] insurance paneling and started to let others know I [would] be open for business Oct. 1.”

Like other first-time small-business owners of all stripes, Stokes was unaware of how much business knowledge he would need to run his own practice. “I had no formal training,” he says, “so I dove straight into reading, researching and seeking out experts in the field of private practice.”

Initially, Stokes’ practice was part time, but as he grew more confident with the business side, he decided to go full time. Suddenly, his practice mushroomed.

“When I took the leap into private practice full time in April 2012, I was eager to build my caseload to a place that was comfortable,” he says. “What I found instead was that I was seeing way too many clients, and the referrals were not stopping anytime soon. I was seeing about 40 clients a week and knew I could not sustain that level of practice.” Stokes realized that without additional help, he would have to start turning clients away, which he was loath to do.

“Simultaneously, colleagues from other agencies were reaching out to understand my experiences in private practice and asked if they could start to see a few clients in my office when I was not there. Little did I know, this was my starting point of group practice development. Being able to serve more clients was an amazing experience. As I began to cultivate my group [practice], I knew it was important for me to bring clinicians on who had different styles, theoretical orientations, different niche areas and populations. This allowed us to build a cohesive practice of clinical services. We now have over 50 licensed clinicians who serve thousands of clients in our state.”

Stokes started with a mission of providing help to the underserved LGBTQ community, but he didn’t anticipate just how much private practice would reignite his passion for clinical work. “I was working in clinics and nonprofits throughout my career. Feeling very overwhelmed, overworked [and] underpaid, I was on the path for early burnout,” he says. “Having my own space was empowering because I was able to design a safe place for myself and my clients. To this day, I am a huge advocate for private practice and helping clinicians find success in this arena.”

When asked what guidance he would give counselors who are thinking of setting up their own practices, Stokes says, “My best advice … would be explore all of your opportunities. Have a good handle on who your ideal client is, where you want to serve and what supports you need [to have] in place as you go down the path of private practice work.”

 

Keeping clinical skills sharp as a counselor educator

Misty Ginicola, a professor in the counseling and school psychology department at Southern Connecticut State University, is primarily a counselor educator. She began her career teaching, but decided that she wanted to keep her clinical skills sharp.

“I wanted to be a more effective professor,” she says. “It definitely helps students to have plenty of narratives on how something might work with a client.”

Ginicola, now an LPC with a private practice in West Haven, Connecticut, decided to focus on two specific populations — LGBTQ individuals and highly sensitive people. She purchased a website and started the process of completing the business application process for her town, registering for tax purposes, applying for a National Provider Identifier number, and getting on insurance boards, all of which took longer and proved to be more complicated than she had anticipated. Ginicola says she fervently wishes she had known enough beforehand to find someone with insurance board experience to guide her through the process.

Striking a balance between teaching, consulting on and conducting research projects, doing clinical work and all of her other commitments requires a bit of juggling and a lot of self-care on Ginicola’s part.

“I put limits on the number of clients I take. I only take a maximum of five clients at a time. I also only see clients during times when it will not interfere with family time,” says Ginicola, the mother of two small children and the president-elect of the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling, a division of ACA. “My self-care is vast and it really has to be. I practice pranayama — breathing practices — throughout my day and coherent breathing every night. I practice yoga every day and am a yoga teacher. I teach three times a week, and it really keeps me working on my own wellness, as I have to practice through the week and stay true to my own physical wellness. I make sure to be honest with myself and to communicate clearly with others what I need. I have learned to say no to lots of things that do not bring me happiness or speak to what I feel is my life purpose, or dharma. By really focusing in on those things, I do not feel overwhelmed. Everything I do truly feeds my soul.”

When asked what advice she would give to counselors who want to set up their own practices, Ginicola says, “Really understand that it involves being a business owner, not just a counselor. Therefore, if it is going to be your primary source of income, it takes a lot of work in setting up and retaining a thriving practice. As a part-time practice owner, the demand is not as much to make a good income at it. I can put a limit on my number of clients, I can choose what insurance boards I truly want to work with, and I can specialize in specific issues. I think establishing a specialization is an excellent way to attract clients and gain referrals.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Private Practice: The Ethics and HIPAA of Technology” with Rob Reinhardt and John P. Duggan (WEBA18007)
  • “Private Practice: Building Your Brand” with Deb Legge and John P. Duggan (WEBA17007)
  • “Private Practice: Managing Your Business” with John P. Duggan and Deb Legge (WEBA18002)
  • “Private Practice: Getting Off to a Strong Start” with Deb Legge and John P. Duggan (WEBA17005)
  • “Counselor Risk Management: Counselors and Technology — A Two-Edged Sword” with Anne Marie “Nancy” Wheeler and John P. Duggan (WEBL18005)
  • “Private Practice: Choosing a Best Fit” with Rob Reinhardt and John P. Duggan (WEBA18004)
  • “Ethics and Values in Real-Life Counseling Practice” with Stephanie F. Dailey and John P. Duggan (WEBA17006)
  • “Counselor Risk Management: What You Didn’t Learn in Grad School That Could Lead to a Lawsuit or Licensure Board Complaint” with Anne Marie “Nancy” Wheeler and John P. Duggan (WEBA18001)
  • “Does One Size Fit All? How to Successfully Get and Keep Your Clients” with Janis Manalang (CPA20695)

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

  • The Counselor and the Law: A Guide to Legal and Ethical Practice, eighth edition, by Anne Marie “Nancy” Wheeler & Burt Bertram
  • ACA Ethical Standards Casebook, seventh edition, by Barbara Herlihy and Gerald Corey
  • Ethics Desk Reference for Counselors, second edition, by Jeffrey E. Barnett and W. Brad Johnson
  • The Secrets of Exceptional Counselors by Jeffrey A. Kottler
  • Counselor Self-Care by Gerald Corey, Michelle Muratoni, Jude T. Austin II and Julius A. Austin
  • Cognitive Behavior Therapies: A Guidebook for Practitioners edited by Ann Vernon and Kristene A. Doyle
  • Creating Your Professional Path: Lessons From My Journey by Gerald Corey

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources/self-care-resources)

  • Self-Care

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

 

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