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Private Practice Startup Podcast
Episode 160: The Three Money Realms of Private Practice
00:31:51
Deb Lyman
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- [00:02]
A
Welcome to the Private Practice Startup podcast where we help ambitious private practitioners across the globe to brand themselves and grow their dream practices. We chat with successful private practitioners, business coaches and marketing experts, bringing you tons of practice building ninja tips. Visit private practices startup.com for awesome resources, attorney approved private practice paperwork and our signature marketing E course. Here are your co hosts, Dr. Kate Campbell and Katie Lemieux. Hey there startup. Hey nation. Welcome back to another episode of the Private Practice Startup podcast. We are super excited that you're here and today's guest is going to be talking to us and you about a topic that you requested. And the topic is the three money realms of private practice. And who we're going to be interviewing today is Deb Lehman. She's a LCSW therapist, clinical supervisor consultant in private practice in Oakland, California. She loves helping early and mid career therapists develop more confidence with both their clinical and business sides of their practices, particularly when it comes to issues of fees and the frame. She'll help you think more deeply about the clinical implications of your business decisions and business implications of your clinical decisions. Welcome Deb, how are you?
- [01:16]
B
I am good. How are you both?
- [01:17]
A
We are good. Little anxious as we prepare for this major hurricane coming, but we are good. Other than that, it's actually good to be here. I know that a lot of times for me, sometimes when life is going on, just being with clients allows me to refocus. So I'm looking forward to this podcast with you and chatting about a topic that we really love to talk about. But before, before we jump in, we wanted to remind you if you did not listen to last week's podcast, you're going to want to make sure you listen to it after you listen to this podcast. Because we had the awesome pleasure of interviewing Mike Michalowicz again. And if you guys know Mike, you probably know that he is author of Profit First. He came back to talk to us and you about Clockwork on how to make your business run like clockwork. And if you are a new timer here, we want to welcome you into the Startup Nation family and we have a gift for you because you are our VIP and that is our A to Z cheat sheet, the essentials for building and growing your dream practice. You can head over to private practicestartup.com head over the resources section and there you'll see it. And we'll come with five days of practice building emails. And that's just our gift to you and really wanting to support you with where you're at in your private practice and of course, if you're a longtime listener, thanks and welcome back. So let's dive into today's topic. How did you start wanting to talk about money and help therapists around money?
- [02:36]
B
Well, basically from messing it up initially, right? As we often do. That's how we learn something and then we want to pass those lessons on to other people so they can make new and different mistakes. So I started my practice and I was told it takes however many years to build up a full practice. And kind of a lot of fear based messages about money initially, like a lot of limiting things. But right around that mark that I was set told, like, this is when you would get your practice going was then the Great Recession hit. It was really motivating for me to actually take a lot more ownership and learn a lot more about business and building businesses and marketing and fees and money. Because initially I do a lot of supervising also. So some of that was as I was doing more supervising, I was seeing all of the up and coming therapists starting their practices, struggling with the same stuff I'd struggled with too. So kind of being the perpetual big sister, I feel like. Tell us a little bit on what I learned so you can make new and different mistakes.
- [03:44]
C
Tell us a little bit about that experience of starting up your private practice just as the recession was hitting. How did that affect you?
- [03:51]
B
Well, it didn't help at all with my scarcity mentality, which I really had. And that just that fear of.
- [04:01]
A
Well.
- [04:01]
B
I'll get into this a little bit when I talk about the personal realm and your own money stories. But it's like I had all those beliefs of what was possible, what was okay to ask for. And the recession just, you know, turned up the volume on all of that. Like, oh, no, it's not okay to charge. Oh no, nobody's gonna want to come see me agreeing to things that I don't think actually were beneficial to my business or clinically beneficial, but that were really based out of fear. So, you know, for example, when I set my fee initially, the fee I chose was initially one that I was like, okay, let me look on Psychology Today and see what everybody else is charging. Let me see what my supervisor is charging. Let me see what people with less experience than me are charging, and let me try and land on something that won't upset anybody. Right. So not the way to do it. Like, there was no math involved in that at all. Right. It was completely emotional.
- [04:54]
A
So I would love for you to share. Deb, like you said, there was no math in that involved. And so, interestingly enough is that we have a video series called Level up. And they're quick, short videos, like 6 to 10 minutes answering startup Nation's questions. And one of the things is we just recently answered, I think twice, it was a question that was similar, but in a different way. And many of the same things that you're talking about is like doing the market research and looking around and trying to figure out, where do I land? How do you do your math in regards to figuring out what your fee should be?
- [05:23]
B
Well, what I tell everybody I work with now is you have to do the math. You have to figure out what your expenses are. You have to figure out what your business expenses are, what your personal expenses are, what you need to make from the practice, and then divide that number, add in the room, the cushion for taxes, and get the number that you need to gross, and then divide that by the number of sessions you're planning on doing. And that's got to be your average fee, right? The average fee. So if you're going to slide at all, if you're going to take insurance at all that reimburses at a lower rate, you need your full fee in quotes to be. To compensate for that. And then, you know, so I'll have people go through the whole worksheet with figuring out all their expenses, doing all the math of that, and then it's okay, what goes through your body, what goes through your mind, what emotions come up when you see that number.
- [06:15]
A
Nice. I like that aspect.
- [06:16]
B
For a lot of people, it's oh, crap, right? Or oh, no, I can't dare charge that. Or, you know, occasionally it's, oh, okay, that's doable. But inevitably there's an emotional response to that.
- [06:27]
A
Totally. And we really like to add in is to also think about the time that you want to take off, the amount of weeks, plan for sick time, how much do you want to save for retirement? Those things are really essential. You know, one of the things as a business owner and growing into a business owner, especially because of all of our learning and understanding and doing marketing and so marketing, they always talk about, like reverse engineering the funnel. Right. Or reverse engineering this message. And interestingly enough, I find, like, when you come into business, you don't have much experience is like, you look down and you're like, I need a business name. Okay, let me pull that out of the hat. And you look down again. You're like, yeah, I need an office. But really, when you're talking about fees, that reverse engineering idea Comes back up, it's like, okay, like let's look at a year time span and then let's work backwards.
- [07:10]
B
Right? Yeah, exactly that. And that was not at all how I had done it initially. Because we don't get business, you know, it's so great what you both offer because we don't get that sort of business training. And certainly thinking about money. In my clinical education, I was think we were encouraged to reflect on our own thoughts and feelings and histories with sex and with substances and with food and all sorts of stuff, but not money.
- [07:37]
A
True.
- [07:37]
C
And as clinicians, we're focused on the care of our clients. And when we are actually stating our fee and putting our needs first and putting that out there, like you were talking about earlier, not wanting to upset the clients. That's something that a lot of clinicians struggle with. I can remember feeling that when I had first stated my fee when I, when I first started out over a decade ago, and I felt like icky and like dirty, like asking to be paid for sessions, like it was this, I don't know, shameful thing. And that was something that took me quite some time to get past. And I know a lot of therapists have issues with money. And if you don't examine your relationship with money and really take a look at that, it will definitely wreak havoc in your business for sure. What are some of the ways that you help therapists to really examine their relationships with money?
- [08:24]
B
Well, just as you were talking about that, I thought, this is why I have this kind of way that I conceptualize money in private practice with these three realms of private practice, which actually are kind of four realms that we've got, the business realm, Right. All of that, the reverse engineering the fee, the looking at the profit and loss statements, figuring out your systems of how you're going to track the ways that money flows in and out of your business, how you're going to do billing, whether or not you're going to take insurance, all of those very concrete pieces, profit first, which I think is a great system in terms of tracking how money flows in and out of your business. There's that business realm and then there's the clinical realm. Right. What you're saying is you had your own fears of what's the client going to hear when I say my fee. But your client's got their own relationship to money. And not just money, but what it means to be paying money to get help, what it means to be depending on a therapist, what it means to be vulnerable in this way. Like all of the symbolic pieces of what money means, both for them, for you and between the two of you. Because it can mean so much. It can mean power, it can mean freedom, it can mean an expression of love. It could mean all realm of things, all manner of things. So there's all of that going on, the symbolic, and then there's the personal. Our own money stories, all of what we're bringing to it, all of our own biases, all of our own fears. And that is so super important to think about because the way the places where the business and the clinical overlap, both of those are being completely influenced by your own money story. And then that whole thing is taking place, you know, in this cultural context at a particular time, whether it's a recession or thinking about the reality of income inequality or, you know, depending on geographically where you're at, what might be happening economically in the local economy, the impacts of, you know, what populations had access to wealth and passing on wealth and who has not. All that's also in the background. So it gets overwhelming, it gets super complicated to think about all those things. Nice.
- [10:39]
A
How about before we dive, dive in. I just want to take a quick break for our sponsor.
- [10:44]
C
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- [12:16]
A
All right, let's dive into those three realms.
- [12:19]
B
All right, so the business stuff I think is, you know, all the pieces that you help out so much with, which is, you know, the structures, the systems, all of that. But what I really wanted to focus on was you were mentioning Katie, that there's. That we get afraid to bring those conversations up, that we get afraid that if we bring in our need into the room, it's going to be, you know, somehow freak the client out, they're going to leave. And so out of our own fears, we avoid those conversations. And so the thing I would really most want people to take away is, is that if you really know your own money story, know your own relationship to money really well, where you get stuck, where you have conflicting messages, that is going to really help you have more confidence in being able to lean into those conversations with your clients and then be able to drop things deeper and drop things into that symbolic realm.
- [13:14]
A
Right?
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B
Because you won't be so preoccupied with your own anxieties or at least you'll kind of know where the landmines are.
- [13:20]
A
Give us a little example about that. Like what questions do you have people.
- [13:24]
B
Ask themselves or explore around their own money history? So many things. Like there's a ton of different factors that influence your money story. So kind of gender, like what messages did you receive? If you grew up socialized female about money and your capacity to earn? What based on your social location, your class background, what messages did you receive about money? Was there enough money? Was what was money? What was the kind of symbolic representation of money in your family? Like, you know, if there was a fight, was it like, let's make it better, I'll buy you something, right?
- [14:06]
A
Or like conditional, like feeling like there's strings attached or you had it. In my family, I felt like I had to earn everything right. Like if I, well, I did get good grades, but if, when I got good grades I would get money or like, oh, if you want, then if you do this. Or my dad. And it's interesting because it's like, you know, I appreciate my dad now because I've appreciate him, but appreciate a lot of what he's instilled in us. And then also there was some money messages that really weren't helpful. I know that my biggest money tape is you have to work hard to make money. And that definitely came from there. Always had to be some type of exchange to make money, and that's really not true. So I've had to work somewhat hard at undoing a lot of those things.
- [14:47]
B
And for.
- [14:47]
C
Yeah, for me, what comes up is I have always been like a spender historically. And the belief underlying that is, I work hard, I deserve this, and I work so hard. And I've worked since I was like, 13 years old, and I have a really strong work ethic that'll never change. But I had to really work on that mentality of not spending so much. And after marrying my husband over a decade ago, we. He's very much a saver and we balance each other out, and it's a really nice, sweet balance there. So I've been able to kind of let go of some of those things. But, yeah, it's so fascinating when you really examine those belief systems and how they inform our decisions.
- [15:26]
B
Yeah, we can do probably a whole other series of podcasts on couples and money, right? Yeah.
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A
Stories.
- [15:32]
B
And you probably see it all the time clinically around money and sex. Those are the things people have a hard time with.
- [15:39]
C
The hot topics.
- [15:40]
B
Yep.
- [15:41]
C
Yep.
- [15:43]
B
So, yeah, so starting to ask about that if there were any significant incidents in your family of origin, if there was a bankruptcy, if there was some sort of. If one of the family members had a gambling problem, if money came and went, if there was scarcity. Figuring. Getting a sense of the cultural messages around money. We're kind of obsessed with money in this culture. So just seeing that there's so many messages we get around that our value is connected to how much we make or how much we charge. Right, right. I think also is like, that's got to get really separated when we're talking about our clinical work because, you know, I ultimately think that most people are paying too much for therapy and all therapists are getting underpaid at the same time. There's that inherent tension. So it's not really about, am I worth X number of dollars for my fee. It's the fee is you figure out the fee with the math. And then the clinical richness comes from exploring all of the emotions that get tied to that and digging in and seeing what it really represents to you and having to kind of sit with the tension of the concrete piece.
- [16:57]
A
Talk a little bit more about, like, what you just said about therapists charging a high fee and then. Then clients. I don't remember exactly what you just said. There's this, like, contradiction and. And how, you know that it's charged.
- [17:09]
B
But what.
- [17:09]
A
What we're paying for therapy. Share a little bit more about that.
- [17:12]
B
Yeah, well, I think we do such important work that it's this idea of like, am I worth $200 a session? Am I worth $150 a session? Like, absolutely. We're all worth getting well compensated for the work that we do and being valued for, for our skills and the gifts that we bring to the community. We're all worth that. It really has nothing to do in some ways with what you're ultimately going to charge.
- [17:38]
A
Gotcha.
- [17:40]
B
And that tension of. I think often there's a wish of I could think in my own history. It's like so many people come in, they don't want to have to be paying for therapy. They wanted things to have gone differently early on so that they wouldn't be needing therapy in the first place. So there's always a little bit of that. Even though I think lots of people come in and really value the work and they don't have a problem paying with it. At the same time, on another level, there's that place of, you know, I'm here because something get what I needed.
- [18:15]
A
Right.
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B
And now I've got to pay for it.
- [18:17]
A
Right.
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B
There's something about that that, like, we all wish that we didn't have to do that.
- [18:21]
C
Sure.
- [18:21]
A
Like if you're going through a divorce or something, like, here we are, I need this. But then having to pay for high attorney and stuff like that. So just kind of looking at. From the perspective of the clients, the consumer and that relationship of. It's a lot different when we are working towards something and we want to go on the stream vacation and we've been paying for it and there's all these emotions attached to it is kind of what you're saying. But when there's an emotional component that's negative of like handing over the money, there's another. I hear what you're saying about the tension that's created there.
- [18:50]
B
Right. Or just even earlier than that, that, you know, that we all have this wish that we could have gotten all of our needs to met as children. And to the degree that we didn't, we may find ourselves seeking out a relationship with a therapist to address some of those things. And so there's. That's always there. Like, I wish you would see me for free and I wish I didn't need you.
- [19:13]
A
Right now.
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C
You've talked about the two different realms. The business realm, the clinical realm. What's the third realm?
- [19:20]
B
The personal.
- [19:21]
C
The personal. Okay.
- [19:22]
B
Like. Right. So the business and clinical they're going to overlap, especially around things like fee cancellation policies, you know, charging from the sessions, all that sort of stuff. And then the personal is influencing all of that, right? An example, the personal influencing the business was, you know, when I first started, there was. I had all those messages if it's not okay to need and it's not really quite okay to be ambitious, or if you are ambitious, you'll be envied and other people won't like you and it'll hurt your relationships. Like all of that stuff was completely connected to the business decisions I was making.
- [19:57]
C
I see this diagram, like a Venn diagram with those three circles and that sweet spot right in the middle. What advice do you have for people who really want to nail in that sweet spot?
- [20:07]
B
What do you mean nail in that sweet spot?
- [20:09]
C
Really explore the sweet spot, like where those three sections all intersect. What advice do you have for clinicians and how they can really explore that area?
- [20:19]
B
Well, first thing I think is knowing your own stuff, right? You wouldn't enter into a conversation about sex or substance use with clients, really, if you hadn't done some of your own self exploration around what are you bringing to that conversation where you get caught up where your bias is, right? So same thing with money. You've got to first kind of know where you're coming from so you can make sense of your countertransference and know, is this my stuff or is this something that needs to be explored in the relationship with the client? So first thing is that second is I think being willing to have things be a little messy for a while. You know, for example, a conversation about fee or somebody's possible resistance to paying a certain fee. If somebody's really erring on the, on the business side, they may just come as like, you know, the fee is the fee. That's the fee. Like it or don't. You could see me or you could see someone else, right? And there's validity in that. But something gets missed, right? If you're leaning really heavily on the clinical side, it might be, okay, well, what fee feels comfortable for you and what can you do on a weekly basis? And let's talk about it and let me be understanding. And you may forget to check, like, okay, can I afford to make those accommodations? That's going to be a big problem too. Being in that sweet spot is being able to hold the tension. I think of there's a reality that the therapist has their own needs and at the same time, this is meaningful in both concrete and symbolic ways for the clients. And if we can hold the anxiety about that a little bit and get really curious and compassionate, I think that can deepen so much. I can't tell you how many amazing conversations I've had with people about what it meant that. What it meant that I was, whatever, willing to discuss the possibility of a fee reduction, whether or not I actually offered it, but to hear more about what it meant for them. Not just what it meant for their bank account and what they can afford, but, for example, you know, thinking about somebody who had their own thing where everything was conditional. So there was a lot of figuring out, like, a lot of fear of knowing they did need the reduced fee, but they didn't want to ask for the reduced fee because they were sort of expecting that some strings would be attached. And so for us to get into, like, what was the right fee, that was like, enough of a stretch for them that they didn't feel like they would then need to leave out a lot of stuff from the therapy. Leave out their aggression, leave out negative feelings, leave out something. Because then they had to be nice to me.
- [23:04]
A
Interesting.
- [23:05]
B
Because they were getting the reduction.
- [23:06]
A
Yeah, I've never thought about that aspect. And of course, as you're talking, like, all of a sudden all these, like, ideas and examples kind of come up for me. And, you know, I think part of it, and I can see, like, how the three realms all of a sudden work together.
- [23:18]
B
Right.
- [23:19]
A
So I've had a client that I've seen on and off for about seven years, and I've kept her fee kind of much lower than my regular. My regular fee. And it was like, kind of like a self check thing. Like, you know, can I do this? Yes, absolutely. Do I want to do this? Yes. Because I enjoy her. I've seen her progress. I'm invested in her as much as she's invested in this.
- [23:39]
C
And it.
- [23:40]
A
And it feels good to do that. Right. So I can see the self exploration in regards to when we do that. And all of a sudden, if it doesn't feel good to us and then we feel obligated and then that's not. And then I've even asked myself, like, if I do this, am I going to, like, start to resent the client? Right.
- [23:55]
B
Oh, and if you do, don't do it. Don't do it. It's really, really bad for the therapy.
- [24:01]
A
Yeah, totally.
- [24:02]
B
They're not gonna get good therapy if there's some way that you're resenting them or then expecting them to not show up with their symptoms or be gratifying in some kind of way.
- [24:14]
C
Right, right.
- [24:14]
B
Because you're ultimately not taking care of yourself.
- [24:17]
A
Right. And some of the things that I know that we have done with suggested to people that we talk to is sometimes there's life situations that happen, maybe someone lose a job or they're getting a divorce or whatever. And to really examine those things and look at that, and maybe you do offer a reduced fee for a certain amount of sessions or a certain amount of time. And that's really helpful. I know. I've learned, too. And I know Kate does this too, on the initial call, because you're right. Is that a lot of times people come up with their own money stuff. So you've had this really good initial call of a potential client. They seem like they really like you, and you get to the fee conversation. And then sometimes they'll say, well, I'll check and let me call you back. To me, I always wonder, like, is it a money issue? Is it something else? So I've learned to just kind of outright ask. And the question I usually say is, was that what you were expecting? And that allows us to have a conversation further. Because for me, ultimately, you know, if someone. If my fee is too high for them, I want to know so I can actually continue to support them and point them in the right direction. And I think it does take something to be okay with ourselves to be able to ask that question, because now we have to talk about money, you know, and that's not always so comfortable. But I see it more as a gift because if I can continue to support you and point you into someone who I know can help you, that I think is a good quality therapist for your needs, then that's a gift for me to be able to do that to you, for you.
- [25:38]
B
Right. Well. And there's so many places that could go if you're able to ask that question of, like, oh, you know, what comes up for you when you hear me say that number? You know, is that what you were expecting? Where is it? There's so many places that can go. It may lead to, okay, let me find somebody that's gonna be a better match. That's really out of my range. It may be something where you could hear, like, maybe they can afford it, but there's some discomfort. And in those cases, I really want to try and if possible, get somebody in the room at least for a session so we can explore a little bit of, okay, what does it mean for you to be investing in this, in this way, investing in yourself, in this way. Gotcha. So even if they could financially do it, but it's so uncomfortable, and if that can get in the room, then we have a different conversation, then maybe my fee is something that they could stretch, or maybe there's a little wiggle room, you know, that we can adjust a little bit that feels like the right number. Where it's a stretch for them, but not so much of a stretch for them that they collapse and have to leave. And not so much of a stretch for me that I am setting myself up to feel resentful or is something I really can't do. But if you're not comfortable, if you don't know your own money story and haven't worked with some of that and are uncomfortable, somebody says, oh, I'll get back to you, your response is more likely to be, oh, okay, sorry, sorry. Bye. Bye. If you're feeling like that wasn't okay thing to ask for, or if you aren't okay with the fact that you can have that and it's not going to work for everybody or they're going to have whatever kind of emotional reaction they have to it, that's okay. It doesn't mean you're bad for charging what you charge. It means money's super evocative for everybody and all gonna have feelings about it.
- [27:19]
A
Yeah, exactly. So I'm enjoying the conversation, really. Like, as you talk about exploring the business realm. So that's the systems, the tracking, the billing, the profit loss. You talk about the clinical realm, the symbolic meaning of money, and the personal realm, really examining your own story. Deb, what do you hope that people take away from your message today?
- [27:37]
B
What I hope people take away is that this is an area that can be so intimidating for so many people, but that when you really start to explore and get into it, not only will ultimately you be able to have a more successful business because you'll feel more comfortable having those money conversations, but your clinical work is also going to really deepen because there's going to be this whole realm that is so, so meaningful and such an entry into the internal world of your client that it's like we're exploring somebody's relationship to food or exploring somebody's relationship, you know, any other important relationship. And when we shy away from that, we miss this whole opportunity to really deepen the therapies. So I want to encourage people to feel more confident having some of those conversations and having them be messy and having them maybe be anxiety producing and that that can be okay. That's, you know, that's what happens for growth, right? Is there some tension?
- [28:42]
A
Absolutely. And there's a book that I want to recommend to you guys, and it's called the Energy of Money and it was actually written by a psychologist and I've actually read it twice and there's a whole bunch of questions really examining a lot of that family of origin stuff for, you know, for those of you who are really interested in this topic. And Kate and I will also put the link to our private practice calculator worksheet B calcul, which allows you to really kind of think through like Deb was talking about in regards to kind of planning backwards in that year to really help and support you guys. And Deb, I know that you have a giveaway for our audience today. What is that?
- [29:14]
B
Yeah, also another Downloadable about the 5 questions you need to ask yourself before talking about fees with clients, which is really more than five questions, but it is prompting a lot of this exploration of your own relationship with money and your own fears about business and what it means to be asking for money.
- [29:32]
A
And a lot of business really is mindset stuff and really doing your own personal work. It's a huge percentage of being in business and being successful. So if you are needing to examine your relationship with money, I definitely would encourage you to utilize these resources. And we appreciate you being here today with us, Deb. We hope you guys join us next week as we talk to Michelle Hardman, talking about the referral network that's hiding right in plain sight.
- [29:56]
C
Yes. And before we do that, let's hear from our Startup nation superhero shout out for today's episode, which is by Emily Dungy. Emily says, I'm working on starting my private practice and just listen, listening to the podcast. I'm so grateful that they have such great resources for clueless people like me. Emily, we are so glad you're finding our podcast to be useful. And it's kind of like, you know, sometimes we need a private practice for dummies, right? Just like the Cliff Notes version and all the different topics and learning from all the mistakes that we've made along the way. So we're glad to hear that this has been valuable for you and we hope you're we wish you lots of practice, practice building success. And for those of you who are wanting to have a topic that we haven't talked about yet, we're always open to providing the most value for you guys. So definitely let us know that via email. Shoot us a message. And also, if you're loving this podcast, don't forget to subscribe, rate and review and share with your friends and fellow colleagues.
- [30:56]
A
So Startup Nation, thank you for joining us on this podcast. Deb, thank you for sharing your knowledge and information and all about money, which is a topic I always love to talk about. And we will see you guys next week. Thanks so much. Have an awesome and inspired day. Startup Nation.
- [31:10]
C
Bye everybody. Thanks for joining us on the Private practice startup. Visit theprivatepracticestartup.com for awesome resources, free trainings, attorney obtained, approved private practice paperwork, and so much more.