Success: how to build a successful practice.
Subject: Psychotherapists (Practice)
Psychotherapists (Education)
Psychotherapy (Study and teaching)
Psychotherapy (Management)
Author: Hixson, Ronald
Pub Date: 12/22/2009
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2009 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Winter, 2009 Source Volume: 12 Source Issue: 4
Topic: Event Code: 200 Management dynamics Computer Subject: Company business management
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 216961295

Most graduate programs give a new practitioner an opportunity to learn and experience a variety of therapy skills and techniques for treating a host of diseases and disorders. The course work is built on a foundation of history, theory, and practice. Graduate schools offer work that can lead to industrial psychology, hospital psychology, research, teaching opportunities, and clinical practice. A growing trend is the introduction of the business side of therapy. But even with all the years of education, one walks out with a diploma and an opportunity--no more, no less. Educational institutions provide a strong foundation and a framework, but an opportunity in the field of practice is the sole responsibility of the therapist. "Caution" and "flexibility" are important words to remember. The training of therapy takes a lifetime of experiences.

Many therapists enter the field with bags of loans and dreams of making barrels of money. The bags are real. The barrels are not. A therapist's revenue stream depends on many factors: career choices, an organization's stability; one's interest peaking and waning; stability or tragedy in one's life; and the strength of one's medical and mental health. All of these issues have an impact on one's energy, interest, well-being, and career length. In the beginning, everyone is excited about trying out their new skills, but that level of excitement can decrease. It's like jogging five miles. The first mile you are happy and full of energy and trying to contain your urges to dash the full five miles. As one gains experience, the need to keep a steady pace intensifies. After a couple of miles a steady gait develops, a rhythm of breathing helps conserve energy, and the use of mental distraction and diversion blocks or filters different stimuli to the sense responders. At some point a realization of the wear and tear on one's body begins to increase awareness of the effects of the run. Runners may question if they should slow down and walk a little. Whether jogging for exercise, for fun with a group, or running a race, these issues are as present in any type of exercise program or sport as they are in the practice of therapy. Years of experiences, especially experiences in diverse settings and populations, add richness and significance for the therapist.

One of the early lessons learned when beginning a practice of psychotherapy is that there is a shortage of hours, a dwindling supply of natural body energy, and while there is enough memory space in our brains, scientists have not found a way to use all of it. After so many years of education, internships, taking tests, role playing, and volunteering, the restraints are lifted. Like a new colt, the newly licensed therapist is released into a field of uncertainty, bewilderment, hope, and excitement. The power of knowledge and the smell of a new career can be intoxicating. So the new therapist races into the field, with nostrils open to all the new smells, eyes dancing in all directions, bucking, kicking and making all kinds of strange sounds of fear and internal turbulence. The therapist is stretching new muscles of awareness; the neural networks burst with newfound energy.

The mental health field offers a world of career opportunities: working as a social worker or psychologist in a government agency or the military; in homeland security non-profit social organization; in school districts as a counselor or teacher; in a college counseling center; working in a hospital as a psychologist, psychotherapist, or social worker; joining a human resources department, an organizational development, or research group in corporate America; or you can join a practice either as a partner or employee. You can also become an entrepreneur and take a chance on being your own boss in private practice. None are sure bets; there are no guarantees, and no lobs secured for life. All come with risks, liabilities, and different challenges. Such risks may turn into expenditures for legal advice. Handling office overhead is no small thing. Creating a budget and working it weekly takes time away from practice, which is the source of revenue that pays the expenses. Find a quality accountant to prepare your payroll taxes, your state taxes, your franchise taxes, and corporate and personal taxes. Putting your name on the door does little except attract finger prints and adds to the costs of doing business.

Be aware of the urge to treat all disorders at once. Limiting your practice interests is important because you can easily get overwhelmed with both patient load and patient resistance. Patient flow is never steady the first few years of practice even if you work in a hospital, government agency, or non-profit service organization. You may sit for days in private practice before making enough money to pay the rent and utilities. You may not get much money in your pockets for months. Some patients do not keep regular hours as their illness may interfere with sleep patterns, and this can cause many to forget their appointments. Some may choose to go shopping instead of keeping their appointment. Your income can be fairly stable if you work with an agency, but private practice work can be more challenging. Patients are capricious, fickle, unpredictable, and many are more knowledgeable about their illness than their doctor or therapist. Some may even create symptoms that do not exist in order to test your clinical skills. There are those who bring their children to the office and ask for an evaluation for ADHD, sometimes unwarranted, because the government sends checks to parents whose children have ADHD disabilities. At $500 a month per child, some mothers are collecting $2,000 or more each month. Single parents are teaching one another how to get the checks, and it gives them an incentive to learn all the symptoms that the DSM-IV lists. Some mothers bring their children in all at once. They may wish to test your skills at handling the same loud chaotic atmosphere in which they are living. Sometimes an employer will limit your practice. For example, the Veterans Administration treats those returning from war and those who have been in the military, retired, or have developed an illness and have no insurance or other resources. A majority of cases will likely have post-traumatic stress disorder symptoms, but there may be comorbidity issues, too.

Accept the opportunity to learn the effects of comorbidity in the daily practice of therapy. There is a connection between the mind and the body that allows for the communication of this message. Starting with the Introduction to Psychology course, students learn about the many receptors that the stimuli bodies employ and how the stimuli travel up the spinal cord to register within the brain where perception takes place. Professors preach about the development of perception and how many ways perception can be misperception. Illusion, delusion, and hallucinations come to mind. The world isn't perfect, and all people are similar in some ways and different in others. Just as the CSI shows emphasize every night on television, differentiation is important. Is your patient's inability to gain insight based on a chemical imbalance, a choice of madness, a cultural influence, or a long road of emotional and physical abuse? Cultural differences can impact tradition and change. Language barriers can interfere with communication. Learning a second language (Spanish, sign language, Arabic, Chinese) is a great asset in many communities. America is at war against terrorism, and issues of terror and torture can impact your organization or your practice. The government has created new careers and organizations to combat terrorism in the Middle East, on our borders, and in the heartland of America.

My practice is in Eagle Pass, Texas, which squats on the river banks of the Rio Grande. Fences and increased border patrol units have been effective in separating the U.S.-Mexico border, but the enemy is very creative, resourceful, and determined. A couple of road bridges and one train bridge have been built in Eagle Pass that allow for transportation of people and goods to travel back and forth between cities and countries. Thousands use these bridges daily; and these people are not all friendly tourists or people visiting family. Mexico is at war against the drug cartels, such as the Zetas who run illegal operations in Piedras Negras, a city in the Mexican state of Coahuila. The Zetas manage the distribution of human slavery, drug trafficking, violence, and money laundering. All of these impact in some way, on the population of both cities and countries. It affects my practice because patients have family members who have been kidnapped, tortured, and killed for a variety of reasons. Sometimes there are ransom notes, and sometimes the Families never hear from their lost loved ones again. The waiting, worrying, and fear of more violence on families places enormous stress on the bodies and minds of patients and their children. Two patients were tortured and survived, but the physical and emotional scars run deep. One patient escaped an assassin's bullet but was left with paralysis that requires 24-7 attention. She is in her early 20s and has a 5-year-old son. The challenge for the therapist is to help her with the transition from a healthy body to one which may not work the way it used to for the rest of her life. Issues of depression and suicide hang like dark ominous clouds over her head.

Therapists have to adapt and be creative. Developing a practice takes lots of time, patience, and relies on a network of referral sources. People will want to know who you are, how long you have you lived in their town or metropolitan community, what services are provided, and the use of talk therapy. A therapist can get lost in the crowd in a metropolitan community. In a rural community, there is no place to hide. You will be asked to contribute ads to the newspaper, radio, and television stations if available. Posters of sporting events are sponsored by companies such as yours. People will ask to see your card, but they are really reading you.

You may practice alone, but there are others in the field that can be of value to your own state of mind. Mentors can be a source of strength for those times when your head is in a fog. Join or create a support group for professionals in the healing arts. Team up with several professional associations that offer resource support. A professional journal, newsletter, or an annual conference presents opportunities for recharging your emotional and intellectual batteries. Start a local association chapter that brings together therapists and social workers. If you work in a rural area, you may have to travel to another city to connect with other mental health professionals. Take continuing education courses offered by the local medical association or the association of physician assistants; these organizations provide exposure and an opportunity to explain how your service can dovetail into their services.

Hiring staff can be an adventure, in metropolitan communities, the quality of skills and knowledge is significantly greater than in rural communities. If you are the only therapy resource in several counties, staffers will expect you to help them and their families. This creates issues of ethics. While most licensing boards will accept a temporary situation, anything else can bring a reprimand or a fine. Small towns have interpersonal communication networks that spread news faster than technology can, so you need to emphasize confidentiality among your employees to protect your patients.

Therapists may find that they spend up to half of their time hiring staff and training new hires. Staffers often lack the sensitivity and insight required to appreciate the need for self-discipline and dependability within a small office. Personnel with families often have family emergencies, and spouses might not care what impact their frequent calls make on the office routine. As the therapist, you are the office backup. No-show employees can create acute stress on a routine that is already fragmented by a high level of no-show patients.


Boosting the size of your practice can be another challenge. Marketing ventures and contracts can put a hole in your financial pocket and sap your energy. Phone book ads aren't always the most effective way to garner new clients, but online ads can bring in a more sophisticated or educated person. Signing contracts with Employee Assistance Programs; HIV programs, such as the Ryan White program; foster care providers; the state protective services for children and adults; and federal pre-trial programs can provide additional referral sources. Becoming a certified sex offender counselor in a rural community and signing contracts with different third party companies can also add to your weekly totals. What this adds up to is a little here and a little there, which can make or break a private practice.

Develop a spiritual life. The number of full-time therapists who work alone is fading, and these professionals may be gone in a generation. Therapists should stand and face the world, offering their lives as an example of one's need for balance, meaning, and giving. Building and maintaining a spiritual life filled with meditation, acts of joy, exercise, and working the soil can sprout new growth and satisfaction while helping you to weather the dark clouds.

By Ronald Hixson, PhD, BCPC, MBA, LPC, LMFT, DAPA

Ronald Hixson, PhD, BCPC, MBA, LPC, LMFT, DAPA, has been a therapist for more than 25 years. He has a Texas corporation private practice and has founded a non-profit group mental health organization where he serves as president and executive director. He has a PhD in Health Administration from Kennedy-Western University, an MBA from Webster University, and graduate degrees from the University of Northern Colorado and the University of California (Sacramento).
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