Running a practice

How To Run A Practice: 40 Years Of Emerging Roles

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I did not have a master plan for learning to run a practice. Certainly, nothing in my training gave me a clue about how the mental health system worked. And I never had a conversation with a professor about the range of roles in the system that might fit me. Instead, as is true for most, my obsession as a student was trying to understand what psychotherapy is. I wanted to learn how to do it effectively. 

I have written elsewhere about my early experiences and some of what shaped me. For example, see these:

This post will summarize the roles I took on throughout my forty years of practice, thirty-five as a practice owner. Certainly, I discovered that ownership means wearing many hats.

Turning into a business owner 

At first, I did not think of myself as a business owner. My vision was simple. I was a solo practitioner who needed office space to do my psychotherapy. I considered myself a clinician like every other therapist and was not much interested in how to run a practice.

But once I had figured out how to manage my own office space, it seemed a small step to lease a larger area and share it with others. Maybe adding colleagues would be less lonely? 

Doing so began to change my vision.  

Meanwhile, changes were occurring in the larger mental health context. Ultimately those transitions put pressure on me. As the power of managed care grew and the insurance system changed, we needed help to stay on top of more things. Credentialling, billing, tracking utilization, and keeping authorizations straight—all drove us toward more standardization. 

I hired support staff. 

As a consequence of adding support staff and the tools they needed, our overhead costs increased. More expense meant more risk. I began to desire a more resolute commitment from my independent contractor colleagues. 

After fifteen years in business, I established an employment contract and converted everyone to W-2 employees. 

Perhaps that was when I realized I was a business owner as much as a therapist. (To read more about independent contractors and W-2 employees, see this post: Picking the best option: Independent contractor vs. employing.)

Additionally, I could see that hiring more staff, and taking more risk, added a personal incentive to nurturing my colleagues’ success. Obviously, if co-workers’ caseloads became more stable, the practice would thrive. And as an additional benefit, staff became more committed as they got more nourishment from the practice.

At this stage, I was unquestionably starting to think like an owner and a therapist. And I was much more intentional about learning to run the practice. (For more, see: Staff development: How to build excellence into your current team.) 

In order to thrive, my business and employees demanded I grow as a leader

Meanwhile, along with the above structural changes, I realized that my colleagues looked to me to lead them whether I felt competent or not. I approached these demands as I had so many other things. I started reading.

Elsewhere I have written about leadership. For example, see these:

Maybe most important to my success as a leader was my willingness to embrace my colleagues’ needs. I tried to understand what made a particular job fit well. Especially with support staff, we were often able to shift duties around to accommodate employees’ gifts and interests. But my clinical team also added ideas for improving things. Together, we tried to make every business process better.

We were attempting to match job duties with staff interests and skills. Sadly, of course, the practice could not meet every need, but understanding colleagues’ desires was an excellent place to start.

Furthermore, my motivation to be a good leader grew. I dug into resources outside our organization to keep us informed of opportunities and threats. My primary sources were trade associations and my relationships with other practice owners. I even took some training with Fred Prior Business Seminars. Check out those opportunities for learning how to run a practice.

I started with whatever God-given leadership skills I had and then tried to reshape myself into the leader I thought my staff needed. I think we all benefited from the process.

My main challenge was as a manager, not as a therapist

As my years of running the practice marched on, I realized that therapy was becoming easier for me. But my role as a manager was becoming more complex. Why more complex? 

First, I had more people to manage. That meant I spent more personal time recruiting, hiring, training, and supervising staff. For more on these tasks, see these posts: The ultimate guide to building your team and culture

Second, the inevitable truth is that the longer people stay, the more they want from the practice. That is to say that the gratitude for “having a job” erodes pretty quickly. In its place grows a desire to reconstruct the job to one’s liking. That is my tendency too. I want every job to fulfill as many of my dreams as possible. It’s human nature.

As my colleagues attempted to reshape the job, the big question was, how do I want to respond? Was I going to let resentment or bitterness grow, as some managers do? I was not too fond of that idea.

David Maister, a business consultant and former Harvard professor, highlights an intriguing dynamic worth considering. He says:

In my experience, the problems of the ill-managed firm frequently derive not from the lack of skills on the part of the manager, but from the unwillingness of others to allow the manager freedom to act.

Maister, D. H. (1997). Managing the professional service firm. New York: Free Press. p. 291.

He then discusses the “salient psychological characteristics of those who choose professional careers”—the strong need for autonomy and to be viewed as an expert. He suggests that together these qualities make managing all professional workers a challenge. 

Increasingly, more of my energy went into managing than into doing therapy. 

My employees convinced me that I knew more about building a caseload than they did

Let me back up just a bit to say that part of my self-discovery was that I knew some things that not everyone seemed to know. By the time I was leading others, I had practiced in several different organizations and communities. In each circumstance, I generated stable caseloads, sometimes with the help of others and sometimes alone. Consequently, I had developed some expertise in building a caseload from scratch. 

As I thought about this issue, I realized I needed to add a new role to what I was doing. I order to run the practice properly, I needed to become an educator and learn how to transmit to my staff what I knew. 

Awakening to the need, I started to formulate a language and method, that is to say, a curriculum. I created a program for training new staff. New hires attended a two-hour monthly meeting for at least one year. Those meetings focused on the many parts of practice ignored in graduate training. Topics included our history and philosophy, how we do our marketing, and some “best practices” about psychotherapy, among others.

Large parts of this website are a distillation of the decades of teaching that followed. My staff became my students, and together we found ways to succeed in growing caseloads and the practice as a whole. 

These posts are about building and maintaining a caseload:

Employees are continually evaluating how well the organization fits them, and they, it. Sometimes, the needs don’t mesh well. 

I cannot depart from this discussion about running a practice without noting a challenging part of ownership—staff leave. I eventually came to understand that my organization fit any particular employee only up to a point. This truth was hard to accept. I wanted to create an organization that met everyone’s needs and desires all of the time and forever. Of course, this hope was ridiculous. Even if there is an ideal match for a while, organizations and people’s needs change. Consequently, the fit doesn’t last forever.

It is hard to watch a mutual synergy dissolve between the organization and a particular employee. It can feel like a personal rejection or failure, especially if the departure does not go well. Releasing them to fly is not easy. However, I never regretted playing a part in an employee’s development. The effort was always worth it, even while knowing that they might move on. 

Eventually, I realized that once an employee decides to move on, my job was to help them do it well, i.e., in a healthy way. I have written more about this in this post: When an employee leaves: Saying goodbye well.

Perhaps owners should become like empty-nest parents. Shouldn’t we learn how to launch those who are leaving and then become their cheerleader from afar? I think so.

The two most fulfilling parts of my career were leading a team and nurturing my clients

As the years went on, serving my team and my clients became powerful sources of purpose and meaning. In choosing to become a therapist, I had some idea of the satisfaction that would unfold. And it turns out I was right about that.

But I was caught off guard by how fulfilling becoming a team leader would be. I just had not thought about what it meant to lead a group of employees. Like working with clients, the satisfaction in contributing to employee growth was fantastic. 

We had many therapists who joined us after experiencing trauma during training or employment. In some cases, they came with serious questions about whether they would continue as a therapist. Observing the emergence of trust, liveliness, and thriving was very satisfying. One of them described our organization as a “hospital for hurting therapists.” What a tribute, even if a bit exaggerated.

I found that striving for a healthy workplace was as fulfilling as my efforts with my clients. And now I see it as significant. A healthy workplace makes doing our job so much easier.

Running the practice means becoming a business owner, leader, manager, educator, cheerleader, and therapist

When I was young and evaluating career possibilities, I thought becoming a therapist was a sure way to avoid becoming bored. I was right. Being a therapist is never dull. 

As I ran the practice, all these other roles grew on top of being a therapist. Fortunately, I found rewards I never anticipated. We built a thriving organization, and I experienced fulfillment in ways I had not foreseen. While I did not do everything well, I remain grateful for all we did accomplish. For me, becoming a business owner-leader-manager-educator-cheerleader-therapist was perfect.

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