The Natural Tensions of a Therapy Business

Many therapists say they’d be happy to work themselves out of a job. And it’s true—we tend to be mission-driven in this work. If we reached a place where our communities supported one another through struggle, resolved conflicts amicably, and ultimately didn’t need us any more, most of us would be delighted to find another line of work.

But in the meantime, we have rent to pay, family members to care for, and debt to manage, just as our clients do. Running a therapy business means making difficult choices about when to forgive clients’ mistakes, and when to prioritize having a sustainable practice.

These choices are at once moral and practical. They’re clinical, and also not. They can be uncomfortable for therapists precisely because they test the limits of our giving nature. But they’re deeply important, because they can make the difference between running a thriving therapy business and having to give up on private practice entirely.

Identifying Common Tensions

Perhaps the most common example of the tension between pragmatic therapy business practices and clinical ideals is your cancellation policy. Most clinicians I know have either a 24-hour or a 48-hour cancellation policy, and clients who cancel after that point are still responsible for their full session fee. 

But what about clients who need to cancel later than that, or miss a session through no fault of their own? What if their child unexpectedly gets sick, or the client gets into a car accident? Even more pointedly, what if the reason a client can’t make their appointment is the very reason they came to therapy in the first place? Clients overwhelmed with anxiety may back out of a scheduled session because it feels like it would be too much to handle. 

In these instances, you usually can’t fill the client’s scheduled time slot at the last minute. From a therapy business perspective, it makes sense to hold the client responsible for their full fee. But as a clinician, it can feel bad to do so. It may feel as if we’re not being true to our calling to help clients heal, or as if we’re punishing clients for having something else in their life go wrong. 

Another common tension is the process of fee setting in private practice. Many of us entered this work to help underserved populations who often struggle to afford high rates for therapy. Raising your fees may be good for your therapy business, but it may feel like it’s running counter to the mission that brought you to this work in the first place. Do you keep your rates low to keep your services accessible, or do you raise them, so you don’t have to maintain a high caseload just to make ends meet? 

Consider, too, how you market your services. Many therapists feel a lot of tension when embarking on any kind of marketing efforts, and struggle to market their services in a way that feels authentic to themselves and their work. Do you advertise yourself as a generalist, trying to get as many prospective clients as possible into your office? Or do you advertise as a specialist, wanting to primarily serve your ideal clients? Working as a specialist may allow you to charge higher fees, but it necessarily means making your practice less inviting to clients outside of your niche.

There’s no single answer to these questions that’s right for every clinician. We all need to balance fulfilling our personal mission with the realities of daily life—including our responsibilities to ourselves, our loved ones, and our communities. 

However, there are some principles you can apply to these decisions so you’re neither resentful toward your clients nor struggling with a failing therapy business. And in many cases, what is good for your business can also be good for your clients.

Addressing Tensions Head-On

The least effective way to approach these tensions is to avoid them. Perhaps you set a policy on fees or cancellations simply for the sake of having a policy, and you leave actual enforcement of the policy up to case-by-case considerations. If you’re comfortable setting and maintaining boundaries, you might benefit from the flexibility you get from enforcing on an individual basis.

But more often, this case-by-case enforcement leads to resentment. Clients cancel their sessions and ask not to pay their full fee, even if they’re in violation of your policy. And given that option the first time, they may expect it every time. Or a client who has been given a reduced fee expects that fee reduction to go on indefinitely, even as their financial situation improves.

It’s better to recognize these situations for what they are—difficult questions that call on you to find a balance that both you and your therapy business can live with. It doesn’t make sense to pretend that these are purely business decisions, and it also doesn’t make sense to pretend that real business considerations don’t impact your clinical work. 

Finding Personal Balance

Your policies and practices need to provide you with enough income to keep the doors open and move closer to your financial goals. But if getting there requires you to compromise the very values that you got into this work to live up to, would you be happy that your business was doing well? 

To help clarify your position and values, list out all the considerations and limitations you believe apply to your work. Perhaps you aren’t comfortable implementing a cancellation policy. Is it because you have a value of honoring the unpredictable nature of life, or is it because you’re worried that clients wouldn’t stick with you if you enforced such a policy?

The reality is that any time you enforce a policy or implement a fee change that results in clients paying more, it can result in conflict and even in clients dropping out of treatment. That risk is worth acknowledging, but it shouldn’t be your only consideration or the most powerful one.     

Finding Balance in Your Therapy Business

In the podcast episode Making Bank as a Therapist, therapist and consultant Tiffany McLain talks about therapists who forgive cancellation fees, waive unpaid balances, and generally charge less than they should. In that interview, she said something that stopped me in my tracks: “By a therapist continuing to nurture [a client] endlessly, it’s upholding a fantasy that adults take care of adults in that way. And that’s not actually true.” 

She was making the argument that what is good for our businesses is also often good clinically because it promotes client responsibility and growth. But getting there can cause discomfort for therapist and client alike, and therapists are often reluctant to take actions that might create conflict in the therapeutic relationship.

In my own practice, I often waived cancellation fees the first time a client needed it, but with a clear statement that it was a one-time forgiveness. Clients didn’t abuse the privilege, and what I lost in income was worth what I gained in client trust. The tensions that come with running a therapy business are real, but sometimes they can be resolved in a way that supports your business while still upholding your clinical values.

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