Preparing for private practice

By Katie Bascuas

April 2022

For many counselors, making the leap into private practice can feel like something of a stab in the dark.

As Logan Williamson, a licensed professional counselor (LPC) in New Orleans, points out, most graduate counseling programs don’t teach aspiring clinicians how to run a business. “It’s unfortunate because universities seem to think that the only thing you’ll be doing for the rest of your professional life as a therapist is talking to people and writing notes,” he says. 

So, while many counselors are well-versed in theory and techniques, they often find themselves learning the administrative side of running a private practice as they go. But there are lessons to be learned from clinicians who have already blazed a path and established successful practices. 

That’s how Williamson learned much of what he needed to know to get started with his practice, New Orleans Counseling, nearly 12 years ago. “I just talked to people,” says Williamson, who was unafraid to approach other therapists and even other business owners for advice. “There is time that goes into figuring it out, and I guess that’s an animal unto itself, and you really have to put the work into it.” 

Erin M. Moss, an LPC based in Buffalo, New York, had a somewhat similar experience to Williamson when she started her practice, Erin M. Moss Mental Health Counseling, six years ago. “I had no road map or role model to look to,” says Moss, who struggled to find other African American clinicians in her area whom she could relate to and who had already established private practices. “There were about two other people that I knew of that looked like me,” Moss says. “I didn’t realize that I was filling a void in my community.”

Meanwhile, for Duncan Price, an LPC in Washington, D.C., launching a full-time private practice seemed like the next step in his career after working in community mental health and managing a part-time practice on the side for several years. Yet the shift to full-time private practice still provided Price with some surprises, from working through the administrative side of running a business to confronting issues that challenged his personal and ethical beliefs.

In reflecting on their experiences, Price, Moss and Williamson all have invaluable advice to offer other counselors who are hoping to go out on their own. While all three clinicians faced similar challenges on their road to establishing private practices, they also encountered some unique experiences and opportunities that helped to shape not only their practices but also their identities as mental health professionals. 

As Moss acknowledges, there is no one way to do private practice. And that may represent one of the most important pieces of advice about running a business as a counselor.

Prepare for insurance hurdles

One of the biggest learning curves associated with starting a private practice involves dealing with insurance. Navigating the insurance landscape can be intimidating and may even keep some counselors from maximizing the potential of their private practice.

“The good thing about taking insurance is that it keeps you very busy,” says Price, who admits that he sometimes questions his early decision to accept insurance because of the added work and responsibility that accompanies it. “I don’t think I was quite aware of the level of administrative duties, particularly with electronic filing and all the entities that are involved to get a claim processed. It took a while to get it working smoothly.”

Price adds that he has sometimes grappled with the idea of whether to take insurance at all. “It would be nice to make more money, but I can’t see myself only seeing clients who can afford to pay out of pocket or to wait for an out-of-network reimbursement,” he says. Price’s practice, DC Recovery Counseling, accepts both private insurance and Medicaid so that he can maintain a connection with the clientele he worked with in community mental health. 

Meanwhile, for Williamson, fear of the insurance world kept him from establishing a full-time caseload of private practice clients as soon as he would have liked. “I felt that there was always a sense that I wasn’t going to get paid by the insurance company for the work that I would do,” Williamson says. “So, I didn’t want to put in time to not get paid.”

After his initial hesitation, however, Williamson eventually began accepting insurance and says his practice grew substantially. “I would say that after I started taking insurance — and I only take two [providers] — it took me six months, maybe, to get a caseload where I was at 20 patients a week.”  

Williamson advises those who are interested in taking insurance to start the credentialing or paneling process early, especially if they are jumping into private practice full time as opposed to building it up on the side. The entire process can take several months — possibly longer with errors or oversights in the application process — and it can turn into a frustrating waiting game with financial consequences. 

“Insurance companies will put you through a process and after three months, they’ll kick something back to you, and they’ll say, ‘You didn’t initial on page 12 at the top,’” Williamson relates. “Now you’re kicked back another month at least or two. That’s really deflating when you’re trying to build up a business.”

Dealing with administrative headaches, which can often be insurance related, was also a bit of a shock for Moss. “There are kinks in every organization — you hear that everywhere you go,” she says. “What you don’t realize is that when all of that is under you, there are a lot of fires that you have to deal with.” 

For example, despite outsourcing her billing, Moss still encounters issues where an insurance company disputes or retracts a payment. When that happens, the onus of fixing the issue falls on her, whether that’s rectifying the problem herself or spending the money to have someone else fix it. “When you’re working for someone else, you don’t have to worry about those things,” says Moss, who acknowledges that managing the operational side of her practice has been one of her biggest challenges.

Tap prior experience

Moss, Price and Williamson all note that the realities of the administrative side of running a private practice can come as a shock. At the same time, all three point to the value of previous work experience in helping them navigate the process of establishing a practice.

Williamson, for one, acknowledges that his path to full-time private practice was a windy one, with several pit stops along the way. After leaving a thriving group practice in Colorado to move to New Orleans to be closer to family, Williamson worked several jobs in the mental health field before returning to private practice full time. He credits those jobs, which included a stint at a university counseling center, time running an applied behavior analysis clinic at a local school, and a position at a major insurance company doing inpatient psychiatric reviews, with providing him good insight into business management. 

“It was on-the-job training that I was able to take with me,” says Williamson. For example, the firsthand experience of managing billing and credentialing for an organization gave him greater confidence and understanding that he could do it later on for himself in private practice. “I think that was helpful to understand — knowing that if I needed to, I could do it, that it’s not impossible.”

Moss similarly credits jobs earlier in her career with giving her a strong foundation in not only business skills but clinical skills. “I worked everywhere, and my case management background has always been strong,” she says. “There was a client sitting with me yesterday, and she said she wanted to open a business, and right away, I gave her the contact for the Canisius Women’s Business Center. It was those early years of going into homes and linking people with services — I can still go back to that stuff.” 

Price advises counselors interested in starting a private practice to not underestimate the importance of developing strong clinical skills. “I think it takes more experience than people think it does,” Price says of clinical readiness. “I’m not saying you have to be a master, but I think it helps doing it on a part-time basis with supervision while also getting really solid training in different modalities.”

Price recommends that clinicians, especially those just starting out, seek additional training at local schools or workshops to continue expanding their skill sets and keep pace with evolving techniques. “I would strongly suggest if someone is thinking of starting a private practice, to make sure that they’re ready clinically and that they’re also investing in continued education,” he says.

Create a support network

Seeking out continuing education can also be an avenue for counselors to expand their professional networks, which can in turn be a valuable resource for private practitioners who are working solo. 

“It’s tempting to think of it as it’s only on you, but if you don’t have a professional network of people that you trust to help you make decisions, then invariably you’re not going to make the right one and put yourself at risk,” Williamson says. 

He gives the example of working with a client who was going through a divorce and having his clinical notes requested by the client’s attorney. Not wanting to be involved in a legal matter, Williamson called a clinical colleague who specializes in client issues related to divorce and asked for advice. “He helped me write my note for that session so that I could send it to the lawyer and not be called into court,” Williamson says. He also provided the client with several therapy referrals that he received from another professional contact who had a wider network in the New Orleans area. “So, I was able to take care of the patient, protect my license and also protect my time because I didn’t have to go through all of that,” Williamson says.

A solid professional network is not only a good place to turn to for advice and consultation. It can also provide socialization and collegiality, which can be lacking in private practice.

“There’s no one next door to say, ‘Hey, girl, what are you eating for lunch?’” says Moss of the lack of office camaraderie that can come with running one’s own business. She adds that she recognized the solitary nature of private practice early on. Over the years, she has actively created opportunities to build in socialization, whether that takes the form of doing administrative work occasionally at a coffee shop where she can be around other people or serving on boards and joining associations and groups where she can volunteer. 

“I’m always at the table learning from like minds in the mental health community and groups that represent some of things that speak to me and my clients,” says Moss, who currently serves on the boards of two mental health organizations in her area. “Even though I’m my own boss, I have always had my foot in the community.”

Williamson also recommends the idea of board membership and suggests that it can be a good way to give back to the community, especially if a counselor’s private practice is less community oriented. “It’s super rewarding, and it’s a low barrier for entry,” says Williamson, who served for six years on the board of a local public service provider. “The commitment is only what you want to put into it.”

Establish boundaries

Given the time commitment that comes with running a business and managing one’s professional network, and then balancing all of that with one’s personal life, setting and sticking to boundaries is another invaluable strategy to implement early on when starting a practice.  

“I used to take clients as they came,” Price says. “And just emotionally, physically, mentally, you can only work with so many clients, especially if some have difficult cases. Trying to find that balance has been hard for me.” 

It can be challenging to turn clients away, especially given the current climate of high need, but prioritizing boundaries and work-life balance is key to avoiding burnout, Moss says. “We’re processing trauma, so it’s so important to have space to not do that,” she emphasizes. “It’s important to have space and time that is just yours, whether you’re connecting with your family or friends or just yourself.”

Moss credits her early years of working for organizations and agencies with helping her realize the value of establishing a healthier work-life balance. “One of my first clinical jobs right out of grad school, they gave me a laptop and a BlackBerry, and I was so excited — like, ‘Who has a BlackBerry?’ Little did I know that was the beginning of my phone never stopping ringing,” says Moss, who now implements a hard stop for herself at 6 p.m. every day. “There’s never enough time, and there’s always something to do, so you literally have to say, ‘I’m done working.’”

Structure for the long term

Although managing a private practice — like any job — may come with certain headaches, it can also afford counselors the opportunity to create and build their dream business. 

“Essentially, private practice is what you make of it,” says Moss, who knew early on that she wanted to create a “super practice” while also developing a professional identity as a mental health advocate. “This is really your show.” 

As part of a small community of African American counselors in Buffalo, for example, Moss realized while building her practice that her scope of practice might not resemble that of other counselors, especially white counselors.

“For me, building a practice and gaining clients, it wasn’t as simple as opening the doors,” she says. “Black people needed to know that it was OK to come to therapy. I had to do a lot of work breaking stigma and free speaking to let people know that this is normal and this is a good thing.” Through that early groundwork, Moss realized a desire to become an advocate and public speaker on mental health issues. That goal has become part of her larger business strategy for her practice and her work as a mental health professional, which she hopes to continue to expand. “I’d love to do more outreach to the Black community,” Moss says. “It’s so needed.”

While having a personal brand or specialty can set private practitioners apart in the market, so can good customer service skills and transparency, says Williamson, who employs a strategy of fostering long-term relationships with his clients from the outset of their work together. 

“I set up the expectation that this is more like a primary care visit for their mental health and they’re developing a relationship with me that can last a lifetime,” he says. “So, we work on the problem at hand and get that taken care of, and they feel good and are discharged, but they always have the ability to come back and talk to someone who knows them and cares about their experience.”

Establishing strong relationships with clients is not only good for business but can also help remind clinicians of their reasons for entering the field or starting a practice, which often lead back to being of service and helping. That sense of purpose can be a source of motivation and encouragement when weathering the more challenging times of business ownership, Moss says. She advises other clinicians wanting to step out on their own to avoid too much overthinking and lean into the process. “Relax and rely on why you got into this in the first place,” she says.

Katie Bascuas is a licensed graduate professional counselor and a writer in Washington, D.C. She has written for news outlets, universities and associations.