Counseling Today, Cover Stories

Finding balance in counseling private practice

By Bethany Bray March 25, 2021

Managing a counseling practice takes strength of both heart and mind. To succeed, private practitioners must find balance between two roles: that of the caring, empathic and client-focused clinician and that of the shrewd business owner, which necessarily involves charging fees and making money.

Most people who enter the counseling profession do so first and foremost because they feel called to help others. At the same time, many counselors harbor dreams of one day owning their own practice, and that involves handling tasks that sometimes go against the grain of their helping instincts. Charging fees to clients who skip appointments or following up about nonpayment or a declined credit card can feel unnatural to counselor clinicians, especially after they’ve spent multiple sessions listening to the person talk about the painful life challenges they are facing.

“This is a tough area to navigate for many therapists, myself included,” says Dawn Altman, a licensed professional counselor (LPC) with a practice in Bryn Mawr, Pennsylvania. “It has been my experience that the most difficult area to navigate is my own money mindset and feelings of worthiness. … Most therapists come to this field with a sheer desire to help people work through emotional difficulties and live a more enlivened life. It feels somehow ‘sticky’ to ask for money for supporting someone who is struggling. The lines become blurred between what comes naturally to most of us — helping others — and requiring payment for our services.”

Money, money, money

One major aspect of maintaining balance between the heart and mind aspects of private practice involves setting — and enforcing — rates and fees.

When she first started her practice, Altman set her fees low because she doubted her own value. “Looking back, what came up for me was what is known as impostor syndrome — that internal experience of believing that you are not as competent as others perceive you to be. This is true of so many women in particular,” Altman says. “I had to get really deep with myself and ask myself, ‘Do you fear success as a business owner more than you want it?’ The answer was, of course, no, so I had to just rip the Band-Aid off and feel the fear and bill [clients] anyway.”

Now, after years in practice, Altman has found that her caseload feels balanced when she reserves three slots in her schedule for clients who pay on a sliding scale. If a potential client requests to pay on a sliding scale and those three slots are already filled, Altman has a list of practitioners to whom she can refer the client so they are not left without options. “I find that this system works for me because I can still provide a service to those who may not be able to afford my normal fee, but I don’t get resentful that I am working for pennies,” says Altman, a member of the American Counseling Association.

Norm Dasenbrook, a licensed clinical professional counselor (LCPC) with a practice in Rockford, Illinois, believes that counselors’ ethical mandate to keep up with self-care includes financial self-care. It’s not greedy to charge what you’re worth; it’s necessary, he says.

“If I’m thinking about how I’m going to pay the rent for my office when I’ve got a client in front of me, that’s not the best care,” says Dasenbrook, who also runs a consulting company that offers trainings and workshops on managing a therapy practice. “Charging what you’re worth is the best care for clients because you’re not thinking about that stuff when a client is in front of you. We [counselors] work hard and should get paid for that.”

Dasenbrook advises that private practitioners who are starting out should ask local colleagues about their rates to find the “community standard.” From there, they should decide on comparable rates and fees and stick to them. Private practitioners should also keep in mind that most clients are not going to shop around and choose a therapist based only on their hourly rate, he says. Rather, that decision revolves around many factors, from a practitioner’s area of expertise to their reputation.

From Dasenbrook’s perspective, the business and empathic sides of private practice are not mutually exclusive. Practitioners can find ways to accommodate clients with empathy while still getting paid, he says. For instance, with clients who are having financial difficulties, Dasenbrook will work out a payment plan allowing them to pay in small installments, or he will offer them half-hour sessions for a lesser fee. In other cases, he will refer clients to local charities or agencies that offer free or reduced-price therapy. These measures all ensure that clients are treated with care and continue to get the help they need, which is empathic, Dasenbrook says.

“To me, [the caring and business sides of counseling] go together. You’re providing a service and collecting a fee. There’s nothing mutually exclusive in there. You can do both with empathy,” says Dasenbrook, who has provided private practice consultations at the ACA Conference & Expo in years past.

Counselors in private practice who struggle with the idea of charging fees should look at how other service professions approach it, Dasenbrook says. He points out that plumbers and car mechanics don’t feel guilty about charging what a service is worth, and he stresses that counselors shouldn’t either.

“Don’t lowball your fees,” he urges counselors in private practice. “Think of other professions. A cardiologist that’s just out of school charges the same as one who has been working in the field for 10 years.”

Bethany Lato, an ACA member with two office locations in the Milwaukee area, also finds that the empathic and business sides of practice management can be interwoven through intentionality and commitment to purpose.

“One way I [incorporate empathy] is by maintaining a clear vision, purpose and foundation for what my business is and who it is for,” Lato says. “When focusing on tasks such as finances, sales and marketing, web presence and long-term business planning, I tend to wear more of the entrepreneurial hat. I think about it from the business perspective: What makes the most financial and business sense in order to achieve that mission?

“From there, I circle back around to empathy: How is this serving my clients and the people that I hope to reach? Am I making sure that I am taking care of my needs while also providing care to others? By beginning my work and concluding my work from a place of empathy, I aim to find that balance and never get too caught up in the business side or in simply making money. Sometimes this comes naturally, and other times it takes a conscious effort to maintain focus on the true mission and what feels truly aligned for myself and the clients I work with.”

Caseload questions

Determining caseload size and finding the “right” number of clients to see per day in private practice is an individualized decision. Counselors must charge high enough rates and take on enough clients to make money and stay solvent, yet still keep their caseloads and daily schedules from becoming so packed that they can’t give clients (or themselves) the time and attention they need.

It’s a balance that varies for each private practitioner and one that must often be determined through experience. Kristy Crump, an LCPC in Bel Air, Maryland, continued to work three days per week in an agency setting as she began her private practice in 2014. Within a year, she was fully booked and able to leave the agency, transitioning into private practice full time.

Finding the right balance was a matter of trial and error, she says. “You have to evaluate how you feel at the end of the day, at the end of the week. I was seeing 10 or 12 clients in a day and would be exhausted and struggling to keep up. It just took time to learn what’s right,” Crump says. “Now, my balance is six [clients per day]. I have some colleagues who say, ‘Four is plenty for me,’ and others who say they can do 10. You have to figure out [a schedule] where you still feel like yourself at the end of the day.”

Dasenbrook recommends that private practitioners start with an end goal in mind when determining their optimum caseload. Do they want to maintain a second source of income, such as teaching or consulting, while operating a private practice? How many vacation days do they want to take each year? Do they want to ease into semiretirement in a few years? Once private practitioners determine their long-term goals, they can work back from there to figure out how many clients they will need to see to meet (or to leave time for) those goals, Dasenbrook says.

Developing a reliable list of referral sources is also an important part of managing caseloads as a private practitioner, Altman notes. Over the years, she has discovered that she operates best when seeing fewer than 20 clients per week. This helps her maintain balance with other facets of her life, including time spent with family and her identity as a “lifelong student.”

“I quickly found out that seeing over 20 [clients] per week does not work for me. I feel pulled in too many directions, and my family life suffers, as does my own physical and emotional well-being,” Altman says. “I am very intentional about the type of client that I want to see, and while it is hard to turn people away, I now have a waiting list for those who want to wait specifically for me, and I have a list of five or six trusted therapists in the community to whom I refer when I cannot accommodate the client. … This alone has made a huge difference to me in my work-life balance because I enjoy each of my clients, and I am not burned out at the end of each week.”

Out of whack

Bryan G. Stare, an LPC and counselor educator who has experience working in private practice, is a critic of what they call the capitalist U.S. health care industry. Many of the decisions counselors who own private practices must wrestle with — whether to see fewer clients, whether to waive fees, whether to do pro bono work — have an effect on the bottom line of their business. This is an issue that often contradicts the counseling profession’s commitment to pursue social justice, Stare says.

“You’re put in a difficult position in private practice. You’ve paid a lot of money for this education, whether it’s a master’s or a Ph.D. To live comfortably, there’s often pressure to charge more for your services. But many of us have entered this profession because of a call to help or for social justice. … It does create some strife there,” says Stare, an assistant professor and director of the clinical mental health counseling program at the University of North Carolina at Charlotte. “We need to take care of ourselves and our business to take the best care of our clients. If I’m not doing that, I’m not able to create a safe space to care for my clients. If I’m spread too thin, I won’t be able to provide ethical and competent care to clients. [But] the system isn’t designed for that; it’s a profit-driven system designed to garner corporate wealth and leave people suffering.”

Navigating this balance requires that private practitioners keep consistent tabs on how they’re feeling about their workload. Only counselors themselves can recognize when their balance is out of whack and they’re spending too much time either on business tasks or client care.

For Crump, it comes down to how she feels at the end of the workday. If she’s irritable or exhausted, it means she needs to reassess her workload. “If I’m not at 100%, I’m not helping [clients] much,” she says.

Crump acknowledges this balance got thrown off when the COVID-19 pandemic caused her to shift all of her client sessions to a virtual platform. Crump specializes in anxiety disorders, and she says some of her clients became needier amid the stressors of the pandemic. In conducting sessions and other aspects of her practice from home, the boundary line between when she was working and when she was “off” began to blur. Crump says she had to check herself and take a step back to regain her balance.

“Of course I want to take crisis calls, but I would soon find myself three sessions over my limit [for the day]. It’s a struggle because you do have that control. You can say yes. I don’t have a front desk that will say, ‘Sorry, she’s booked for today,’” Crump notes.

Stare, an ACA member who counsels a small caseload of clients in addition to teaching and research work, agrees that emotions are a barometer. Private practitioners should recognize signs of burnout and regularly process their own feelings. Stare’s support circle consists of trusted friends, colleagues and mentors with whom Stare can consult.

Multiple private practitioners interviewed for this article say their bodies give them clues — such as feeling tired, worn out or achy — that indicate their professional balance is out of alignment.

“We teach our clients to do this, and we have to listen to our own body and our own needs too, and nurture ourselves as we tell our clients to do,” Crump says. “We have to take steps back and reflect. It gets very stressful. Some days are really hard. I’m a full advocate that every therapist should have a therapist — they can help keep you in check too.”

Lato notes that somatic cues tell her not only when her workload is imbalanced but also when things are going well. When her work is in balance, “I find myself genuinely excited about my business and my practice, rejuvenated by my sessions with clients, and with vivid dreams and visions of what the business can be in the future,” Lato says. “It is that vision that often gets me through the difficult, out-of-balance times as well. I spend a lot of time journaling, meditating and vision boarding around the future of the business and my practice, and find it is always important to know where you are heading. With this clear vision and direction, it becomes easier to recognize when things are out of balance.”

Put it in writing

The counselors interviewed for this article agreed that one of the best ways private practitioners can minimize the need to have difficult conversations with clients about payment is to offer clear, thorough communication about fees and expectations before any counseling takes place.

Crump provides a full explanation of her policies in the informed consent that clients sign at intake, but she also talks the policies through with each new client before they begin counseling work. “It took me a while to get a flow to be able to speak about that to clients,” admits Crump, an ACA member. “It’s hard to say, ‘Hi, hello, I have a cancellation policy.’ … [But] if you are genuine, you’ll get that in return. When I let [clients] know my boundaries and no-show fees, I’m being honest. I explain that it’s ‘housekeeping.’ It’s important to talk about it, get it out of the way and separate sessions into counseling and noncounseling work.”

Enforcing professional boundaries, such as imposing cancellation fees on a client who repeatedly no-shows, also models healthy behavior for clients, Crump adds. “I’m teaching boundaries to all of my clients, so I want to make sure I have boundaries myself,” she says. “I make sure to set boundaries with clients from day one. I’m direct, and if I answer a crisis call in the evening, I talk about how this won’t become a regular thing.”

Yet Crump acknowledges that she still finds it hard to charge fees, even after years in private practice. It presses on her empathic reflex, she says, because she doesn’t want to discourage people from seeking counseling.

“I hate having the conversation to this day,” she says. “It’s hard because we’re in a helping role. We’re here to help, and it doesn’t feel congruent with what we’re taught. You’re imposing a boundary on them, but unfortunately, that’s part of the business. There’s no one to enforce that but me. It’s easier [when] you talk about it upfront, instead of waiting until it happens and then springing a fee on them. It’s a necessary evil that you have to do. At the end of the day, you’re running a business, and you have to pay bills yourself.”

Crump and the other private practitioners interviewed for this article say that before enforcing a cancellation fee, they usually extend a one-time grace period for clients who miss an appointment. They also make exceptions for late or lesser payments from existing clients facing hardships such as an unexpected job loss. However, they agree that charging fees to clients who are chronically late with payments or repeatedly miss appointments is a necessity.

“I will usually say to the client, in writing, ‘Twenty-four hours’ [cancellation] notice affords me the opportunity to offer your appointment time to a client who may be on a waiting list or who needs an urgent appointment. I hope you understand that I must charge you for missed appointments,’” Altman says. “Being upfront about fees and payment options is crucial in setting up a good relationship with the client and [establishes] the clear boundary that therapy is a valuable service for which payment is expected.”

Enforcing fees not only helps to ensure that a private practitioner’s finances stay in the black. It also sends a message that counseling requires commitment and intentionality from both parties — counselor and client.

“At the end of the day, if I don’t set a boundary, I may not be acting therapeutically,” Stare observes. “If we’re not meeting regularly or semiregularly, depending on [a client’s] presenting concern, we’re not going to make therapeutic gains. Ethically, I can’t provide services that aren’t going to help.”

Dasenbrook urges private practitioners to spend time crafting thorough informed consent documents. Including details such as the hourly fee for services provided outside of counseling sessions (e.g., letter writing, filing court documents) ensures that clients are fully informed prior to being charged, he says.

Language centered on client consent, privacy laws and other practice issues varies from state to state, so private practitioners should seek training and consult with local colleagues and their state counseling associations when creating informed consent documents. “These are the people who are going to know the funky laws” in your state, Dasenbrook asserts.

The language in informed consent documents needs to be thorough and firm yet welcoming and calming, Dasenbrook adds. Clients filling out these forms are seeking therapy, so they may not be in their best mental state, he points out. They shouldn’t be made to feel as if they’re doing something akin to signing the seemingly endless number of pages involved in buying a home. Breaking informed consent into sections — treatment of minors, telebehavioral health, fee schedules, privacy laws/release of client information, etc. — makes things easier for clients to digest and allows counselors to remove sections that do not apply to particular clients. Per the 2014 ACA Code of Ethics, practitioners must include information about alternative/continuing service options should the counselor experience an emergency or pass away.

Ultimately, the time spent creating thorough informed consent documents should mean fewer confrontations with clients regarding fees and other policies down the line. “The business piece [of private practice] should be all taken care of in your informed consent,” Dasenbrook says. “It should be communicated upfront, before we even say, ‘What brings you here today?’

“Put it in writing, and get it all out ahead of time. … You want to take the money piece out of it [counseling] as best you can, and that’s why [I do it] all upfront.”

Getting down to business

The professionals interviewed for this article shared the following tips and insights on blending counselors’ caring instincts with the business side of running a private practice.

>> Maintain separate spaces: Stare uses an existential humanistic approach that recognizes the importance of feelings of place. With that in mind, Stare recommends asking for and accepting client payments in a space that is separate from the counseling room. If possible, keep a credit card machine or other payment mechanisms in another room and walk there with the client to take payment. Not sitting in the same chair and in the same room where therapy takes place to accept payment helps separate the two concepts for counselor and client alike, Stare says.

>> Pay first, talk second: Crump recommends taking payment from clients at the start of a session, before any counseling takes place. Crump didn’t always follow this process but eventually adopted the approach to avoid the awkwardness of having to transition from discussion of heavy, therapeutic topics to request for payment.

Keeping a client’s credit card number on file for automatic charging can also be beneficial if practitioners find it a good fit. Dasenbrook notes that private practitioners now have many convenient payment options, including apps such as Venmo and PayPal, compared with when he started in the profession three decades ago.

>> Stay on top of housekeeping: Tackling those unappealing tasks right away can be a benefit to private practitioners and their clients. For instance, Dasenbrook says, if a client’s credit card is declined, call them right away; don’t put it off or even wait until they come in for their next session. Addressing it immediately gets the issue resolved and is more likely to result in payment.

Similarly, Crump stresses the importance of filing insurance claims and paperwork as soon as possible after client treatment. This is especially important with new clients, to find out whether the private practitioner’s services are covered or whether the client has a deductible to meet. The sooner a practice owner knows there is a gap in a client’s insurance coverage, the sooner payment arrangements can be made, especially while the session is still fresh in the client’s memory. “Even though those case notes take longer, it’s worth it [to file right away],” Crump says.

Altman notes that a tough-love approach is sometimes necessary when tackling tasks that might go against a counselor’s empathic nature. “I used to offer monthly bills, which the client could then submit for reimbursement. However,” she says, “I found that several clients would simply ‘forget’ to pay. Their bills were racking up, and I was feeling resentful over both not being paid and the time it was taking me to have to rebill every few weeks.

“One client in particular would not pay me in a timely manner, and his bill would go unpaid for several weeks. I sent multiple reminders via email that he did not respond to. When the bill was a month overdue, I emailed him the bill one final time and told him that I was unable to provide the Zoom link for our next session until he had cleared up his account. He paid the bill immediately, and at our next session, I began with [talking about] the issue of payment. We agreed that moving forward, he would simply pay weekly, which he has done since that time.”

>> Play by the rules: Crump recommends that practice owners determine their “hard and fast” rules and endeavor to stick by them. For Crump, this includes taking Friday and Sunday off each week. She blocks those days off on her client schedule. In addition, although she doesn’t mind working in the evenings on occasion, she will build time into her schedule on a subsequent morning or afternoon to catch up on administrative tasks.

Another rule Crump has established for herself is never to send a client to collections for nonpayment. “I don’t see the need to cause unnecessary harm to those [clients]. If they could pay, they probably would have. It just doesn’t feel right,” Crump says. “Also, it [collections] is just one more thing to learn how to do and keep up with.”

>> Don’t do it all: One good way private practitioners can keep from becoming overwhelmed is to wield technology to their advantage, Dasenbrook says. This includes building a practice website with client intake and screening forms that ask for a person’s home address, insurance details, emergency contacts and other basic information. This negates counselors having to spend time asking for and transcribing this information in person or over the phone.

Dasenbrook also recommends that practice owners consider using software or hiring a professional to handle administrative tasks that they dislike or struggle doing themselves. That’s what Dasenbrook does with billing. “If there are tasks that you don’t like, then hire it [out],” he says. “You can try and do it yourself at first to learn and save money, but ultimately it makes sense to hire out if it causes a headache and takes too much time. Once your practice grows, start farming some of that stuff out.”

>> Seek and value supervision: “The No. 1 tip I would offer is to spend the money for high-quality supervision,” Altman says. “I had an incredibly gifted supervisor whom I worked with when I began, and it made a huge difference in the amount of time that I had to spend ‘winging it.’ Most of our supervision hours were spent on case discussion, but sometimes we talked [about] the business of private practice. It was enormously helpful to me as a business owner. Peer supervision is another great way to connect with others to share tips and insights and to just have a sounding board for cases or for life as a therapist in private practice.”

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Necessary skills

Private practice management demands a wide variety of skills, from overseeing scheduling and billing to determining one’s caseload size and handling client referrals. A successful private practitioner must also hone a number of skills beyond the nuts-and-bolts tasks of managing a practice, says Norm Dasenbrook, a licensed clinical professional counselor with a practice in Rockford, Illinois.

Dasenbrook considers the following qualities “musts” for private practitioners:

  • Clinical competency and excellence
  • Healthy self-esteem, self-awareness and the ability to set boundaries: This involves knowing what you’re good at and what you’re not, Dasenbrook advises.
  • The ability to know when you’re over your head professionally: This involves realizing when a client’s needs go beyond your skills and that you should seek consultation. Dasenbrook has been a counselor for three decades and still runs into issues for which he seeks consultation from peers. “It happens to everybody — when you’re sitting in session and you have no idea [how to help a client]. We’ve all been there. I’ve been there many times,” he says.
  • A business mindset and inclination for bookkeeping, scheduling, keeping medical records and other administrative tasks
  • Being comfortable with taking risks: “Sometimes we fail, but we keep on going,” Dasenbrook says. “You need to see yourself as an entrepreneur. Some things won’t work out, but you learn from it and move on.”

What skills would you add to this list? Post your thoughts in the comment section of this article, below.

 

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Action steps to learn more

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Pro bono: Yea or nay?

The 2014 ACA Code of Ethics encourages counselors to “contribute to society by devoting a portion of their professional activity to services for which there is little or no financial return.”

What role does pro bono work play for private practitioners who are trying to balance their empathy with the financial side of running a business?

Explore this topic further in an online companion piece to this cover story, “Pro bono counseling: How to make it work.”

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@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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