Let’s Start by Keeping It a Hundred

I know it. You know it. Everybody who is a therapist knows it—we barely if at all get any training in how to build, run, and grow a private practice. For most of us we definitely did not have any courses in graduate school. Maybe when we were on internship or fellowship. 

Maybe.

We might have had a graduate or faculty member come in and talk to us about their practice, getting on insurance, getting a website, getting on Psychology Today, maybe even something about SEO. But what is SEO you ask? I could not even begin to tell you back then, as I probably forgot whatever the presenter said. It was a bit over my head at the time. Still, it didn’t seem that difficult—finish psychotherapy training (oh, the youth!), get your license, get a job, open my practice. Piece of cake. 

So I did the thing—I got my doctorate, passed my licensing exam, and got a job. My first job was as a psychologist and faculty member at a teaching hospital, which offered an in-house private practice for faculty. The hospital was in a diverse community with substantial clinical need, which was part of my interest as somebody committed to cultural competence and social justice. At the same time, the faculty practice was a selling point of the position for me at the time. I wouldn’t have to pay rent for an office, the practice had their own billing department so they could submit out-of-network insurance claims for my clients, and there was the possibility of cross-referrals with other faculty. All I had to do then was set up my website and Psychology Today profile, and I’d be good to go and let the referrals flow. Easy-peasy.

My First Run at Private Practice

Dear reader—whether you are a seasoned clinician, graduate student, or early career professional—it may surprise you to know that things do not work this way. I know. I was just as shocked to find out as you are right now. While I did over time build up a private practice caseload at the hospital, there were some major growing pains. Perhaps the first issue I had to contend with was setting my fee.

Oh, the fee.

As someone from an ethnic minority background who specialized in working with low-income and culturally diverse populations, I agonized over what my fee should be. If I set it too high, would I be marginalizing and excluding the patients I want to work with, both at the hospital and at my practice? Initially, there was no such thing in my mind as “setting your fees too low.” It felt like it had to be very low. Eventually, I reasoned to myself that since I was already serving patients from communities in need during the day as part of my “day job,” I needed to justify the extra evening hours I was spending in my private practice. I set my fee higher, at a level commensurate with the “market rates” in New York City, and later figured out a flexible system for having conversations with potential patients about the fee, and when to lower the fee to make treatment more accessible. 

While this was a learning process in which I became aware of the beliefs I had around money and how they emerged from my family history and cultural context, what struck me at the time was what would happen when I broached the topic of private practice with my mentor, supervisors, and therapist friends. Of course, when I started out it made sense to reach out to them. They had been in private practice much longer than I had; surely they have knowledge, experience, and wisdom to impart. So, I started asking how they ran their private practices. How did they set their fees? What was it like starting out? How do I grow my practice?

The same pattern would emerge. We’d be discussing the latest article in Psychotherapy, a recent training in this or that treatment approach, or the latest Game of Thrones episode, maybe even gossip about the latest intrigue in this program or that organization (Oh you know we’ve all done it). Then I would just bring up a question about private practice.

The awkwardness was palpable. 

It was like some taboo had been crossed. People stumbled over their words trying to answer my question. At times it almost felt like they had some “trade secret” they dared not share, lest it lead to some kind of competition in the psychotherapy market. At other times, I sensed some shame, as if questions about private practice risked exposing something about them as therapists, business owners, and people. Maybe everybody struggled with private practice in some way. Whichever the case, after a while I just stopped asking.

I continued my small practice after work, slowly trying to build without really knowing what I was doing. Or more precisely, whether what I was doing was actually helping my practice grow or not. Without some mentorship or people I could talk about private practice openly with, I decided it was time to really reach out, this time to an expert—enter Dr. Google, MD, MBA, PhD, PsyD, EdD, Esq.

The good doctor had an unending list of prescriptions for me to follow for a successful practice—start a blog; get on Instagram; get on insurance; get off insurance; don’t blog, vlog instead; identify a niche; get a logo; work on your SEO; don’t ever get on insurance; clarify your message; why the fuck are you on Instagram?; and so on and so on. Not really knowing how these different components worked and in what sequence, I tried all of them. It turned out to be pretty overwhelming trying to write a weekly blog, come up with content, edit, re-edit, and re-re-edit a website, or playing around with Google Ads. After a while, I realized that the usually effective behavioral technique of throwing spaghetti at the wall to see what sticks had failed me. I was too burned out to keep trying to figure things out. With my day job and daily life already being busy I stopped focusing on my practice. At least, until it was time to leave the hospital.

How I Learned to Stop Worrying and Really Really Reached Out for Help

A combination of professional goals and life changes made me decide to leave my position at the hospital. I took a part-time faculty job where I would teach and supervise, leaving me with plenty of time for a private practice. In getting ready to leave, I knew I’d be taking a plunge into the unknown. I would be running my own practice, initially subleasing an office, and would need to grow it in order for things to be sustainable. In my search for resources and information, I had come across not only blogs and downloadable pdfs about private practice but stumbled into an entire cottage industry of private practice consultants. These were typically psychotherapists who had learned the ins and outs of building a successful practice and ran a side business helping other therapists build and grow their own. In some cases, consulting for other therapists had become their primary source of income, while continuing with a smaller therapy caseload. 

I wasn’t sure what to make of these people at first, to be honest. Were they running some sort of racket, seducing unsuspecting therapists into giving them their hard-earned money with the promise of clinical and business success? Could I really trust these therapists turned entrepreneurs? This was not an easy decision to make. On the one hand, working with any one of them would cost money. It was one thing to rent out office space or pay a Psychology Today subscription. But to truly invest in my practice? Into learning the skills, tools, and knowhow for running my practice? It seemed foreign to me, as strange and alien as the idea of having a return on my investment.

I started out small, enrolling in an online course offered by one of the consultants I found online. The course felt within my budget, it followed a weekly sequence that would run during the time I was winding down at the hospital, and included a cohort, meaning I would be taking each sequence with a group of therapists sailing in the same unknown waters. The consultant running the course was very fun, dynamic, and down to earth. I enjoyed my time in this course and got to learn from other therapists struggling with the same questions and conundrums. Through it I was also introduced to other consultants in this industry, some of whom also provided one on one consulting. 

Having a good experience with this course, and learning actionable steps and skills for practice building, really impressed on me the value of not just asking your friends or mentors, not just looking up free and available information on the internet, but of investing in your practice. By the time I finished the course and was wrapping up at the hospital I was set and ready to transition my practice from the faculty practice into my own setting and my own terms. Based on some of the initial changes I implemented, I started having a more steady flow of good fit, full fee patients, and patients with whom I collaboratively set fees that worked for them to make our work accessible, especially where there was a good fit on both sides. I literally saw the money I had invested paying off, for me and for my clients.

Based on my initial experience, I contacted one of the consultants I had been introduced to and applied to work one on one with them. This would have cost more money than the course, but it felt worth the investment to have some real guidance and mentorship. This consultant was also very down to earth, pragmatic, and with a great sense of humor. But they also had access to a wealth of information on how to market one’s practice in this day and age and build a brand that reflects one’s personality and style. Ultimately, what leads potential patients to have that initial experience of “This person gets me” even before they pick up the phone or send you that e-mail.

We worked on identifying my “message” to the clients I want to work with, and then using that message to redesign my website copy (e.g. the material you write for your website) and Psychology Today profile. We came up with a plan for blogging at a pace that worked for my schedule and got connected with a separate company that has experts in designing Google Ads for therapists. All of these orbited around my message, which emerged organically from the populations I was passionate about—young adults and professionals of color. I learned that tailoring my message to the people I wanted to reach first did not exclude or prevent others outside that focus from reaching out for therapy, but it did give a needed vision for who I wanted to serve. More importantly, after all was said and done, I had way less writing on my website. 

It turns out we therapists can get wordy. And people don’t care about what we have to say or where we earned our degrees. Potential clients care about our message getting across to them loud and clear, and about how that message makes them feel.

Once things clicked into place, my calls increased dramatically. I feel more secure in my practice and had access to a community of therapists that spoke openly not just about our clinical work, but about the nuts and bolts of creating a humane, conscious, and successful practice. And just as importantly, a lifestyle that nourishes and supports our clinical work in turn.

Things I Learned Along the Way

This essay reflects my experience becoming comfortable with reaching out for help and investing in how to build, run, grow, and nourish a private practice. In that spirit I want to share a couple of tips that could be useful to other therapists:

• Buy a copy of Building a Story Brand (Miller, 2017). If someone ever wrote a book on marketing for therapists, it would be this book. And it’s not even written by a therapist! It describes how to harness the power of story to clarify one’s message. Every story has a hero, a villain, and journey. We often write our website copy as if we—the therapist—are the hero of the story. But it is the patient who is the hero, the issues that bring them to therapy the villain. We are the guide that helps them on their journey. Clarifying this message sets the tone for everything else in building one’s practice.
• Research private practice consultants: There is a plethora of them available online. If you find one whose style and message you click with, check out their free content.
• When you are ready, invest! Building a private practice can be a lonely and stressful experience. It doesn’t have to be that way. A good investment in a resource, a training, or a tool for growing your practice is likely to yield a good return.

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Daniel Jose Gaztambide, Psy.D.

Daniel José Gaztambide, PsyD, is the chair of the Professional Practice committee of Division 29. He is the assistant director of clinical training in the department of clinical psychology at the New School for Social Research, and director of the Frantz Fanon Center for Intersectional Psychology. He is the author of the book A People’s History of Psychoanalysis: From Freud to Liberation Psychology, and a psychotherapist in private practice. He was featured in the documentary Psychoanalysis in El Barrio.