Learning to Love the Entrepreneurial Side of Therapy
by Lynn Grodzki
One hot summer afternoon John, a psychotherapist in private practice for 17 years, came into my office looking frustrated, complaining that his practice was going nowhere. Not that he didn’t like doing therapy–he still loved it–but he felt stuck and frustrated in the practice itself. His income had barely inched upward over the past few years, he wasn’t getting his name and practice out in the world as he wanted, and he felt increasingly overwhelmed by paperwork, as if the business part of his practice were running him, not the other way around. When I asked him to explain what he meant, he sighed and described the chaos of his office: journals, newsletters, papers, insurance forms, notes, bills, and whatnot were stacked on the desk, the table, the chairs, the floor, to such an extent that it was difficult to get around. “I know I’m really good at what I do, and I have dreams of expanding my practice and developing more of a reputation in my field,” he said despondently, “but I can’t seem to get organized to do anything about it. I thought I’d feel more settled and directed by this age, but I don’t.”
John’s experience wasn’t at all unusual. Psychotherapists don’t go into clinical practice because they’re such great businesspeople. They want to be helpers and healers, not entrepreneurs. Although most of them recognize the advantages, in terms of autonomy and income, that working within a private practice brings, the business world and terms associated with it–such as profit, expansion, competition, even “success” itself–tend to make many of them uneasy. In short, therapists tend to regard business as alien to their practice.
I find that, with business coaching, therapists can learn to become very smart businesspeople. Far from being a struggle against their own better instincts or a betrayal of their own best principles, becoming more entrepreneurial can be deeply liberating. I can actually allow therapists to be more effective, less anxious, and less psychically split between their “good” clinical practice and their “bad” business.
After John finished describing his frustrations and the rat’s nest of paper that was his office, I asked him to mentally take a step back, so he could better examine not only the state of his practice, but his relationship to it. Therapists tend to overidentify with their practices. As sole proprietors, they frequently do everything and take every role in the business–clinician, CEO, administrator, bookkeeper, secretary, janitor. With so much of themselves wrapped up in their practices, it isn’t surprising that they tend to think they are their practices. This overidentification is one key reason why therapists feel unhappy in business. When the business is up, their mood goes up; when the business falls off, they crash, too. In their fused state, they often can’t recognize the difference between what they want and what the business needs.
One way to help clients differentiate themselves from their practices is to ask them to imagine the practice as a distinct entity from themselves–another person, so to speak. True, they created the business, but no more than their own child is it an undifferentiated extension of themselves. “If your daughter needs braces,” I sometimes say, “you don’t refuse her orthodontics because your own teeth are perfectly straight.” I asked John if he could talk to me about his practice as if it were a separate being, with its own individuality, personality, needs, and behavior.
He laughed nervously, but agreed to give it a try. “Should I make it a male or a female?” he asked.
“Your call,” I replied.
He thought for a moment. “Well, my practice is definitely a she, ” he said. “She’s timid and boring. She’s also pretty rigid–she only knows how to do things one way, and she sticks to it, even when it’s illogical. We’ve gotten along okay, so far; she’s a familiar, safe presence in my life. But I’ve known her for more than 20 years and she never changes. I’m bored with her.” John paused, looking ruminative. “It wasn’t always this way. When we first met, I was thrilled by her–she got all my attention and energy. But now, my attention is drifting. I want something more.”
John suddenly reddened, looked at me open eyed, and barked out a laugh. “I sound like the world’s biggest clicheÂ´! I get it now. I’m having a mid-life crisis,” he said. “I want to have an affair, but it’s not my wife I want to leave, . . . it’s my private practice!”
The great thing about working with therapists is that they frequently get the picture very quickly. John looked out the window for a minute. “This is ironic,” he said, a little sheepishly. “I specialize in working with couples, and here you’re reminding me that when you’re in a relationship for two decades, even a relationship with your business, things change. The question for me, I guess, is what the changes mean and how they’ll play out. Will I need to leave this timid, messy lady–and all that we’ve built up together over the years–in order to get what I want now?”
We looked at each other and smiled. “Welcome to business ownership at mid-life,” I said.
Finding a Road Map
When seeing therapists who are struggling with their relationship to their own practices, it’s crucial to have a broader developmental framework to help break up the logjam keeping them stuck. Certain similar themes consistently emerge in the early, mid-life, and mature stages of a small business. As a business goes through the early stages, its owner is consumed by survival, competition, and stabilization. During the mid-life stages of a business, issues such as organization, expansion, and achievement take center stage. Later, during more mature stages, the “successful” businessperson focuses on renewing personal values, finding more affiliation with others, and incorporating a greater sense of integrity.
The developmental model I use in my business coaching with practitioners like John is adapted from Spiral Dynamics, Don Beck and Christopher Cowan’s work on social and organizational evolution. I focus on the specific objectives and tasks suggested by their model, actions that small proprietors need to take at each of the eight, color-coded developmental stages of business development. Working in this way, I recognize the stage a business is in by the themes my clients reveal as they talk to me about their private practices.
Any beginning entrepreneur, including a therapist, in the first (beige) developmental stage, is primarily concerned with survival. Clients in thisÂ stage typically complain of feeling insecure, panicky, and clueless about what to do next to keep the business viable. Inexperienced and driven by anxiety, they operate mostly on instinct, and the best way to help them is by teaching them to replace instinct with intention and planning. I usually begin by helping them devise a business plan that leaves as little as possible to chance. This might mean writing down their short-term goals and long-term vision for the practice, deciding on specific networking steps to take and how many hours each week to network, scheduling time to consult a financial advisor or a computer expert, if needed, and creating a circle of professional support, such as meeting regularly with other therapists, who can be a source of guidance and encouragement. These suggestions are often met with surprise and resistance–“It’ll cost too much money!”; “I don’t want to get all these other people involved!”; “I should be able to do this stuff myself.” It always amazes me that clinicians invest freely and generously in their own clinical growth–paying for clinical supervision, taking advanced training courses, attending workshops, buying textbooks–but consider investing in their businesses a kind of unnecessary extravagance.
The second (purple) stage often reflects a superstitious, even magical, way of thinking, and parallels cultural eras when people feel dependent on rituals and traditions, often without practical or rational basis. At this point, a business may be surviving, but the entrepreneur has no idea why–no idea what he or she’s actually doing that makes the thing “go.” Not knowing how to keep on being successful, they tend to cling to comfortable rituals and habits, almost from a sense of dread that if they change anything, the success will go away. For example, one therapist told me he had four different bank accounts in three different banks and randomly deposited his clients’ checks each week into all of them. “Why?” I asked him, suggesting that consolidating them would make better financial sense. He shook his head and repeated doggedly that this system had just “worked” for him up until then, and things might not “work” if he changed it. Several therapists have told me that when they lose clients, they believe that if they don’t allow themselves to worry and just visualize abundance, new clients will show up. They insist that if they think about their situation too carefully, it stops the flow of clients. Many clinicians have no idea how clients discover them, where the referrals come from; the appearance of new clients remains a vast mystery to them–a gift from heaven. Not knowing what they’ve done to get clients in the first place, they don’t know how to keep doing it.
Helping these therapists unravel the myths and mystery of business and implement practical, concrete strategies, while they learn the laws of cause and effect, empowers them. They feel less anxious as they see that can take steps to create their own business destiny. Writing business plans and setting goals; determining how much they want to earn and how to set and raise their fees; deciding what their policies are (about cancellations, for example) and what factors determine client retention; knowing how to effectively market, network, and generate referrals–all this information can help them understand how a therapy business works. Such steps normalize business operation, make it less confusing, and help them become savvier entrepreneurs.
Finally, in the early stages of a business’s growth, there’s the red stage–what Beck and Cowan call the egocentric phase–when a strong sense of individualism and selfhood comes to the fore. With survival secure, clinicians begin to have some practical sense of what they need to do to keep their businesses afloat and start concentrating more on staking out their own professional identity in the world. At this stage, a proprietor knows she’s developed something substantial, worth protecting and preserving, and begins to look around at all the potential rivals she has–how many others in her area also specialize in addictions, or adolescence, or couples’ counseling? How’s the clinician going to stand out from the throng?
Therapists often have a hard time with competition. While it seems perfectly normal for a car salesman to be competitive, it feels perverse to therapists, who aren’t happy to find themselves thinking envious thoughts about colleagues and obsessing about how they can get ahead of the pack. It sounds so narcissistic and unbecoming in a mature, selfless healer!
In contrast, because clinicians often don’t understand the normal mind-Â set of an entrepreneur or how to accept themselves as competitive beings, they may overreact to theÂ presence of perceived rivals. OneÂ therapist I saw had identified a colleague in her area–with similar credentials, professional history, and specialty–as someone she needed to match and keep up with, step for step, as if her own career somehowÂ depended upon how her colleague did. She found herself trying to second-guess the colleague–angling to present at workshops where she thought the other therapist wouldÂ also present, for example. What helped her negotiate this particular stage was refocusing on her own personal vision for her professional life, reconnecting with what it was about the work that she loved, what sheÂ wanted for her own career. Getting back in touch with her original vocational foundations helped her stay on course with the goals that wereÂ Â Â important for her professional development and act to determine her own identity as a therapist, rather than react with one eye always on somebody else’s progress.
When John described the chaos of his office–journals, papers, insurance forms, and whatnot stacked on the desk and the floor–and showed me his old-fashioned calendar with a jumble of scrawled names and appointments, I knew he was having trouble negotiating the fourth (blue) developmental phase, which focuses on organization. People at this mid-life stage need to create stronger, more functional, business structures to support their dreams of enlarging their business and becoming more profitable. John’s frustration came about because he wanted to branch out and pursue greater opportunities, but he hadn’t completed the tasks required by the blue phase of his business. He had ideas and dreams, but didn’t have the structures in place to make them happen.
Although people have to learn that their businesses stand alone as separate entities, it’s also true that because people’s businesses are their own creations, they necessarily reflect key strengths and weaknesses within them. However distinct your children are from you, undoubtedly they also reflect your genes, your values, your capacities as a parent. At times, the easiest way to help a therapist change a problem in his business, is to see whether he can make a similar change first, in himself.
I told John that he needed to think of his business as a mirror of himself. What was it in his life or in his childhood that might contribute to the mess of his office and the paperwork that was essentially drowning him? John said he’d never been a well-organized person. As a young child, his parents had moved many times. Again and again, he’d been uprooted from familiar surroundings, friends, and schools, leaving him feeling that nothing ever really belonged to him. Nothing, that is, except what he could physically carry with him from house to house, state to state. Rather than teaching him to pare down his belongings and travel light, the constant moves made him ferociously attached to his “stuff.” Once John understood the connection between the origins of his pack-rat mentality and their effects on his business, he could begin, with difficulty, to take steps to change his business practices. Reluctantly, he admitted that this problem was more entrenched than he thought; he needed to bring in someone to help him fix it and agreed to hire a “clutter consultant,” a professional he found in his local paper, who came to his office and completely banished the clutter and reorganized it.
John focused on other “blue” issues of organization, including how to use what I call a Practice Upgrade Plan–which I developed to help a small-business owner bring more stability and substance to the business and enhance its reputation in the community. Through the Practice Upgrade Plan, I encourage proprietors to build into their daily schedules time for planning and actions that will strengthen the long-term prospects of their practices. For example, this is the stage for a therapist to decide his top five business goals for the next year and to take one action every day toward these goals.
After several months, John found, to his delight, that his business was easier to operate: his billing was done on time each month, he’d collected past-due receivables, and his clean office and new, computerized calendar made his weekly administrative tasks a breeze. With his newfound energy, he was ready to move into the fifth (orange) stage and focus on expansion and achievement. John was jumping with at least three new ideas each week for expansion that interested him. Once people acquire a new set of eyes for gazing on a world of sparkling possibilities, they also need a filter for sorting all those opportunities. I suggested that he develop a set of six questions that would help him evaluate each potential opportunity. His questions were:
1. Is it, or will it be, profitable, and when?
2. Will this allow me to do better work as a therapist?
3. Will I have fun doing this?
4. What’s my gut feeling about this opportunity?
5. What do I gain if I say no?
6. What do I gain if I say yes?
How did these questions help John sort through the onslaught of possible opportunities? One of his colleagues who had many legal contacts had built a practice of couples therapy with court-referred families. He asked John to join him in setting up a partnership to offer workshops and training for other mental health therapists who do the same kind of court-referred counseling. The colleague said the referral rate from the courts and lawyers was substantial, but many therapists didn’t know how to do strategic, effective counseling with this population; he and John would show them. Using the six questions above, John thought that it could be very profitable, but only after about two years of hard work and marketing the workshops. He was expert in couples counseling and enjoyed training others, but decided that this project, while interesting in itself, wouldn’t actually help him become a better therapist. As to whether it would be fun and what his gut feeling was, John said, “I’m not sure. I like the guy quite a lot, but the ‘fun’ part of the deal would probably be outweighed by the sheer drudgery of getting it off the ground.” What would he gain from saying no? More time to pursue interests that he really knew he liked. What would he gain from saying yes? Possibly a new income stream–training could be a good profit generator down the road. In the end, John decided against the offer since the negatives seemed to predominate.
Marketing is itself a daunting word for therapists, who generally loathe any suggestion of self-promotion. To help them conquer this hurdle and begin taking marketing steps networking, becoming involved in community activities, teaching courses at local adult ed colleges, writing articles for local newspapers, etc.–I imbue them with the basic principle that should undergird all their business-building efforts. Base your actions on love, not fear. Fear-based marketing, for example, would be a therapist who grimly settles down to make phone calls to people he doesn’t know well, detesting the whole process and saying, “I loathe doing this, but if I don’t, my practice won’t survive.” In coaching sessions, we talk about these feelings, and I ask, “Is it possible to imagine a way of doing this that might not seem so bad, might even make you like it?” Generally, we get into a discussion of the clinician’s love for her own work and pride in her vocation, her deep belief that she does have something good that will truly help people, her realization (beneath the reluctance to make the call) that the person she’s calling might be glad to hear about what she’s offering and welcome collaboration.
One clinician I worked with called an oncologist she knew. She told him how much she admired him and his reputation for kindliness and patience with scared, desperate patients, and said she wanted to let him know that one of her own specialties was working with very sick or dying people and their families. This clinician made the call in a spirit of love for her work, for the good she knew she could do, and from a conviction that she and the physician might make a very good team. The doctor felt both flattered and receptive–here was someone to whom he could refer people for the kind of help he didn’t have the time or expertise to give.
At this heady stage of entering orange territory, feeling an upsurge of personal power and emotional zest, many therapists become aware of a small, tough little worm gnawing away at their euphoria, signified by the words ambition and profit. These terms, along with competition, so normal to the business world, are often anathema to therapists. John, for example, would be energetically talking about potential new opportunities when suddenly, looking crestfallen, he’d say something like, “Boy, I’m beginning to sound like a real estate developer, not a therapist.”
Again I asked him what it might be in his family of origin that made him so uncomfortable with ambition and profit. “My father was in sales and worked for a variety of bosses,” he began. “He often complained about his current boss and how owning a company gave a person a swollen head. We weren’t poor, but he was always worried about money and it was a constant source of tension in our family. I want to be able to retire someday, and I need to make more money. It’s now or never. But I get a lot of negative thoughts and feelings when I try to stretch too far in the direction of seeing this as a real business and making more money. I begin to feel that I’m selfish and attention-grabbing, and I can hear my father saying I’m getting too big for my britches and setting myself up for a fall.”
I often invite proprietors to “embrace their ambition”–clearly a tough sell for therapists, who think that too much emphasis on ambition and profit signify self-absorption and greed. So I suggest to clinicians that they think of ambition as a kind of emotional fuel, a motivating force that frees their passion, imagination, and creativity. Ambition is really a synonym for desire, emerging from the same impulse that helped get them through school, then into training internships, and, finally, into their own private practices. I suggest they ask themselves what they fear about ambition and then allow themselves to do a little daydreaming about their ideal future. What–no matter how apparently improbable, grandiose or Walter Mitty-ish–would they most like to see happen to themselves and their businesses? They don’t have to act on every ambitious thought or fancy, but allowing their minds to wander in this way helps detoxify ambition and gets them in touch with their own aspirations.
After orange, there’s another swing of the pendulum to a third, latter-life evolutionary stage with its own phases, the first of which is green. If orange is characterized by the drive for achievement and material success, green represents a move in the other direction, toward the integration of more humanistic values into one’s work life. The characteristics of this stage are a desire for deeper personal or spiritual connections, a yearning to experience again the soul-deep inspiration that brought them to the work in the first place. People signal they’re ready for this stage when they complain that, for all their material and professional success–the practices (perhaps several offices) purring along at full occupancy, the workshops they’re asked to conduct, the book chapters they’re writing–they feel something lacking. Green is the color of congruence, when any incongruity between professional success and personal identity becomes painfully obvious.
John, who’d just entered the orange stage and was exuberantly enjoying the world of prospects and achievement after having been in a safe, but confined business situation, wouldn’t be ready to shift into the next (green) stage for a while. But another client, Clara, is experiencing “symptoms of green.” A social worker with many years of experience, she no longer sees clients. Instead, she owns and operates a healing center that she built from a solo operation to a prosperous, 15-person organization housed in a large commercial property that she owns in a busy Midwestern suburb. She employs mental health professionals, massage therapists, and physical therapists. She’s an excellent businesswoman and a natural marketer, who actually enjoys calling total strangers to talk about her practice. She considers each call a kind of adventure into the unknown.
But when Clara called me, she said that, in spite of her obvious success, she was feeling dissatisfied and burned out. She felt tired much of the time, and although she had a heavy workload, she thought this tiredness was from feeling less personally connected to what she’d built. More and more, she felt less like a healer with a real gift for connecting with people in pain and more like the harried CEO of, say, an expanding widget plant. “As each year goes by, I feel less sure about my direction,” she said. “I’m always marketing, planning, or thinking about some business problem–staffing, expansion, leveraging our space needs, or looking for increased areas of profitability. I wanted to create something meaningful with this center, something that would genuinely help people and contribute something to the community. I’ve done that, I think. But I’ve kind of lost sense of what it means to me. I feel I’ve lost something important, which I had when I was just struggling to make ends meet.
“And besides, ” Clara said forlornly, “I feel lonely. I don’t know any nearby therapists in my situation that I can talk to for support. All the professional clinicians I know imagine I couldn’t possibly have any complaints or needs. It sounds like a joke, but I’m a case study of ‘lonely at the top.'”
Sometimes, in the midst of material success, we forget that even though we’ve “made it,” we’re still evolving. The pendulum doesn’t stop swinging just because we now command a six-figure income and a staff of subordinates. Since the classic signals of a business owner who’s entering the green stage are concerns about isolation and lack of meaning, the objectives of that stage usually include building a deeper community, relaxing boss-employee hierarchies by sharing more power, and taking steps to renew old passions and explore the spiritual dimensions of life.
For clinicians in this stage, I’ve created a checklist of 60 evocative words that elicit core values–including, for example, “creativity,” “learning,” “enlightenment,” “sacredness,” “compassion,” “adventure,” “inspiration,” “accomplishment,” “understanding,” “wholeness,” “connection,” “fairness,” and the like. I ask therapists to pick their top four that they feel define them and their work at some fundamental level. Which words, I inquire, draw from them an almost automatic sense that “this is really me?” Next, we look at whether those values are now reflected in their practice. What would bring more passion into their work lives? How can they make their professional lives more deeply congruent with their deepest values? Because the hallmark of coaching is to help people take action–not just speculate about personal philosophies–we then work on concrete steps to bring their practices more in line with their ideals.
Since one of Clara’s core values was “healing,” she began to realize that she missed the hands-on experience of doing therapy. So she hired a part-time operations manager to take on some administrative tasks, freeing her to see a few clients every week. At the end of the year, she reported feeling exhilarated again about her work, having rediscovered her fascination and passion for doing therapy itself. During this time, she also created a professional network of about a dozen business leaders who met regularly to talk about their concerns, and a smaller, more intimate, circle of entrepreneurs who became friends as well as associates. She now felt the “connecting” instincts that drew her to the field in the first place had been reborn.
There are two stages beyond green–yellow and turquoise–which represent, each in its own way, a leap into a transcendent kind of thinking and feeling about work and professional identity. The yellow stage–a phase of deep creative regeneration–occurs when a seasoned, mature, successful entrepreneur makes a profound life change and breaks away entirely from his or her old route to explore new territory, just for the sake of newness.
At one workshop, for example, I asked attendees to talk for a few minutes about their practices–where they felt they were in the trajectory of profession and career, given the eight, color-coded stages of evolution. After several practitioners had spoken about their aspirations and frustrations–most were in the early and middle stages–one woman raised her hand and said that she and her husband had built a successful group practice. “I feel now that I’ve achieved every professional goal I set out to achieve, including what many here today are still seeking,” she said. “Now I’m ready to do something completely different. Next year at this time, I know I’ll no longer be associated with this practice. I don’t yet know exactly what it is I’m going to do–though I’ve got some ideas–but I know it’ll be a departure. My husband and the group aren’t happy about my decision, but I feel very deeply that it’s time for me to go off on my own, in an entirely new direction.” As she spoke, the room became very quiet; she was clearly at a different crossroads than any of the others. When I asked the attendees what stage they thought she’d approached, they shouted out, “yellow.” A therapist at this stage is willing to provoke some chaos, relying on her flexibility and the synchronicity around her. Her knowledge and competency as a therapist and businessperson are retained and integrated as she ventures into this new phase of life and work.
The last stage is the rarefied turquoise stage, an idealized “holistic” domain, in which business owners see all the many levels of interaction possible and utilize the state of “flow” for the best, easiest performance from individuals. Turquoise businesses are attuned to the delicate balance of interlocking life forces and aspire to spiritual connectivity. As exclusive a coterie as this stage represents, many people nonetheless can experience turquoise moments–states of flow, when thinking, feeling, and action seem united.
Marla, a psychologist in private practice for a decade, says there are months at a time where she feels that her therapy business operates effortlessly. In the early years, she did a lot of hard work–making contacts, finding the right office, getting her policies to reflect her values, building her reputation and her skills. She joined associations to keep her name out there, spoke at any conference that would have her, and learned how to fill a practice with referrals so that she could side-step managed care and stay independent. “My practice stays as full as I want it to be,” she says. “I make good money, I gross over $100,000, which is enough to support myself and my family and to have the life-style that I want. I love the clients I work with. I love the work I do. I get to take whatever training appeals to me to stay fresh and motivated. I feel very connected within my community and have a lot of professional support around me. I don’t have to hustle or promote myself in any way. Good referrals come in regularly, from all the contacts I so carefully made in the past. I can be very selective and only see clients I want to work with. After a long day of seeing clients, I don’t feel drained. Instead I feel full, as though I just finished a very satisfying gourmet meal.”
Meanwhile, back on planet earth, we therapists are mostly still trying to reconcile the ethics and values of our chosen profession with what we often feel are the unsavory truths of the business world. And yet, it’s the business itself, our own business, that gives us the most freedom to practice our vocations with the greatest degree of integrity and personal choice. As therapists, we often consider ourselves to be masters of change. If we can begin to see that our businesses are themselves evolving organisms, with their own identities and strengths and weaknesses–just like our clients–we might be better able not only to master the process of their change and development, but to enjoy watching them, and ourselves, grow.
Lynn Grodzki, L.C.S.W., P.C.C., is a psychotherapist and business coach in private practice. She’s the author of Building Your Ideal Private Practice and 12 Months to Your Ideal Private Practice: A Workbook and editor of The New Private Practice: Therapist-Coaches Share Stories, Strategies, and Advice . She can be reached at her website: www.privatepracticesuccess.com. Address: 910 La Grande Road, Silver Spring, MD 20903. E-mails to the author may be sent to email@example.com. Letters to the Editor about this article may be sent to Letters@psychnetworker.org.