A healthy therapy private practice has a natural ebb and flow in its caseload.
Clients conclude therapy once they’ve reached their treatment goals. Other clients might end due to graduation, moving away, and other life changes. Due to these fluctuations, therapists get influxes of clients at certain times of the year and have less at others. We all know it’s part of the profession.
AND YET, when caseloads are on the decline or we’re not getting any new inquiries, it can be incredibly difficult to not fall into a scarcity mindset. In this place, anxiety ramps up as we begin to worry about our income, the state of our practice, and more. We start scrambling to do more marketing or discern the next best steps to get people in the door.
This anxiety can be even worse when you are a premium fee therapist with a small caseload. I charge $300/80 min and typically see about 8 clients a week. One client concluding therapy has a dramatic impact on my income level - as does gaining a new client.
When I had a caseload of 40+ and saw about 25-27 hrs of clients a week (my fee on average was $84/50 min), I didn’t feel the financial impact of a client starting or concluding. Furthermore, with that many clients, there was a significant amount of clients starting and concluding every month (usually about 4-6).
When we have intentionally small caseloads that are in an ebb phase, our minds can easily worry, “What if another concludes? Or even two?”
These high levels of angst continue until we suddenly get a new inquiry that turns into a new client. Our nervous system relaxes and remembers, “Oh yeah, I’m going to be ok. This is how it works.”
I would like to get out of this anxiety cycle.
However, I don’t think the way out is just “trusting the universe.” I’m part of a network of therapists who are currently raising their fees to premium fee levels. Much of the initial work involves addressing our money mindsets so that we feel comfortable charging a premium fee. Many people “make the leap,” set a new premium fee (meaning something $200+), and “trust it will work out.” They may suddenly get a new client at that fee and explode with enthusiasm (that also happened to me - I got a new client the day after I raised my fee).
That enthusiasm quickly erodes though when months go by and no new clients come in.
Getting clients at premium fee levels is vastly different than getting clients at standard rates.
I will say it again because it needs emphasis. IT IS VASTLY DIFFERENT.
If we solely raise our fee and do not augment our current marketing approach, it will not be enough to fill a caseload at that level.
It takes intentional work:
Creating a website that truly captures you (great design, copy, photos, SEO, etc.).
Having a clearly defined niche that differentiates us from other therapists.
Creating new referral networks (reaching out to other premium fee therapists, creating consultation groups, etc.).
Refining copy wherever we advertise our services (making ourselves stand out on Psychology Today, etc.).
These things are the essentials - a foundation. Things I would argue that every premium fee therapist needs as a baseline. They require a lot of work upfront, but have lasting, sustaining impacts.
And then there is the endless supply of marketing ideas that we “could” be doing. Podcasts. Blogs. Writing for others. Google Ads. Social Media.
All of these things take time, energy, and work. We cannot do them all or afford them all, thus it is pivotal that we select marketing strategies that match who we are.
For example, since writing comes naturally to me, I write a lot of essays. Another therapist may enjoy creating tik-toks. Another therapist may have a marketing budget of $500 and choose to pay someone to help them make great Instagram posts. It all depends on our natural talents, time, and budgets.
Given there is an endless supply of options, it can be difficult to know when we’ve done “enough.” To know we’ve laid a strong enough foundation that we can trust the ebb and flow. That we can truly feel our business will move through the phases of the moon and it will be ok.
For me, the first step is acknowledging what I’m feeling. “Oh yes, I’m feeling some anxiety coming up because another client just concluded therapy and I only have 7 clients now.”
Before I dive into “what more can I be doing,” I check in on my true parameters. One of my reasons for reducing my caseload was that I wanted to enjoy my life more. I wanted more time to relax, be with my loved ones, enjoy my hobbies, and more. If I am worried about my business and scrambling to do more, I have traded one kind of stress (operating with a high caseload) for another (frenzy to build my caseload).
I do not want to be in that space. And hence, I need clear parameters. For me, if I drop below $6000/mo gross income, that is my sign that I need to invest more in marketing. I chose $6000 by looking at my personal and business budget. $6000 is enough for me to meet my essential expenses (I then rely on my savings for superfluous spending).
So, if I lose a client and my anxiety arises, I tell myself, “Jackie, you are above $6,000. Clients come and go. Give it some time. Enjoy what you’ve created.” For me, right now, that looks like me seeing my 8 clients, and enjoying all the free time for writing, extra naps, and whatever the hell I want.
Now, if I drop below $6,000, that’s when I know I need to invest more time and effort in marketing. I can do a self-audit of my foundational items - are my website, referral networks, and advertising operating at the optimal level? Is my niche clearly defined? What tweaks can I make? I may also invest in a coach to help me see what I cannot (I have done this in the past).
I can also look at what additional marketing strategies I’d like to pursue: Pitch to podcasts? Reach out to more doctors? Blog more? Run some groups? Provide some workshops? The options are endless - and another reason it is helpful to touch base with a coach or marketing expert.
With time and consistent effort, these efforts will produce results. They will help us reach a stable income.
A private practice instagram account noted that the first 10 clients of a new practice are the hardest to get. After that, systems start to become self-perpetuating (our existing clients provide referrals, our referral sources know we’re a solid place to send people, etc.).
I think the same applies for premium fee clients. The first 10 premium fee clients (not counting existing clients that we raised to our premium fees) require the most time and energy.
When we’re in the thick of investing our time, energy, and money into marketing, we can remind ourselves that it will not always be this way. That we will get to a place that is more sustainable.
And once there, we need to protect what we’ve created. Set parameters so that we know when to act and when to shield our minds from anxiety. A place where we can trust the ebb and flow, and trust ourselves to take action at the right time if needed.
I provide consultation for therapists who want
thriving private practices that honor their needs.