The Surprising Problems of Having a Full Practice

by Joe Bavonese, PhD

We all know that not having as many clients as you want in your practice causes serious problems in your life. What is not commonly understood, however, is that a whole new set of problems also occurs when you have a full caseload. My agenda in this email is twofold: 1) if your practice is not yet full, to give you realistic expectations of what may occur – behaviorally; financially; emotionally and interpersonally – when you reach your practice goals, and 2) if you’re already there, to learn how I successfully dealt with those challenges, to give you some ideas of what your options are. Read on…

I can still remember the exact week in October 1997 when my practice first became full. Full as in “holy crap, there’s nowhere to put this person who wants to see me next week!” I was ecstatic. I had been working on this goal intensely for four years – studying business, trying new things, reaching out in the community – and here it was! I sheepishly told my client (trying to sound like this happened all the time) that I didn’t have any open slots next week but I could see them the week after. The client seemed slightly relieved and made an appointment for two weeks. I called Mel and two other friends to tell them the good news. I called my Dad. I did it! I was on Cloud Nine for two days, totally oblivious to what was to come.

I got another referral, and another. What to do? I squeezed them into time slots where I don’t usually work. I rationalized that I could work 1 or 2 extra hours a week and it would be okay. And it was ok for two more days until I got three more referrals. Ut-oh, now what?

I referred all three out to other colleagues, who were of course more than willing to take them on. I felt good that I was helping my friends and making sure these clients were well taken care of. And this became the pattern for the next five weeks – referring out 2/3 of the referrals I got; extending my hours (and taking even more time away from family); feeling a combination of fulfillment, guilt and pride.

But then I started to feel something else: resentment. Resentment toward my colleagues that I was referring to, and resentment toward my practice itself. I was throwing away hard-earned money. And I was not running the practice, it was running me. My schedule was really getting out of control and it was causing problems at home.

And then the kicker happened. After a bad thunderstorm ripped a huge hole on the roof on our house. Turned out we needed a new roof. And despite my full practice, I couldn’t afford to pay for the roof without using credit. Then it hit me like a ton of bricks: this was it? This was the Holy Grail that I had been dreaming of, and I couldn’t even repair my roof? How was I going to save for retirement, or my three kids’ college education if I couldn’t even repair a roof?

So in addition to resentment, I started to feel panic…just like when I used to see those empty time slots in my appointment book. But I thought this was…How could I make more money? There’s nowhere to put anyone! Well maybe I could…no, no, no, there are no more hours in the week. I obsessed about this day and night. I felt like a high-price line worker whose only recourse was to work hours of overtime to make more money. But in our field, I knew there is a limit to how many hours you can really work and be effective. I was already over my limit and I felt squeezed. I obviously needed to make more money but my current business model – exchanging one hour of time for one unit of money – had reached its max. My elation in having a full practice was completely gone in less than two months. I felt like a former client of mine who had lost 120 pounds – her lifelong dream – only to find that all of her life issues did not magically melt away with the weight. She had resentment for all the people who suddenly wanted to be her friend – and fear from all the men suddenly hitting on her.

I decided to take action. I called my Business Coach and he said “Well Joe, this is an opportunity. You need to leverage your time better. Hire people to work for you and generate passive income.” I really didn’t appreciate the ‘opportunity’ comment. It sounded trite and cliche. But truth be told, I needed to do SOMEthing different, so together we created a plan to hire three therapists to work for me. How hard could this be? Very hard.

Have you ever been in a plane taking off in a heavy storm? Well that’s what it felt like: lots of bumps, jerking up down and sideways; can’t see where you’re going; not sure when it will end. I realize now I was woefully unprepared for that journey. It was trial and error at its worst, mostly error. I hired the wrong people. I didn’t have enough space. I underestimated the administrative tasks. I didn’t realize that therapists would project their authority issues on me. I tried to do everything myself. I worried more about being liked than running the business well. I worked even more hours than before, and ended up with less money at the end of the month. All the referrals wanted to see me, not the people working for me. I kept incompetent staff working, giving them far too many chances to improve.

I knew it wasn’t working, but I didn’t know what else to do. My Business Coach was trying to guide me, but I was resisting his suggestions. On the verge of quitting the whole thing, I finally let go and opened myself up to learning some new things.

Here are some of the most important things I learned:

  • I realized the old adage ‘spend money to make money’ was really true. So I hired an Office Manager and got a bigger office with 4 offices and a group room
  • I learned how to create Systems – essential for managing the flow of information in a much more complex system than a solo practice
  • I learned how to interview & hire staff (both administrative and clinical) and the quality of both increased significantly
  • I learned how to evaluate staff performance and when necessary, fire people
  • I learned how to create clear, unambiguous contracts and expectations for staff
  • I learned how to calculate how many referrals I needed to keep my clinical staff full
  • I learned how to generate more referrals to fill those slots
  • I learned that it was okay if my staff didn’t like me or everything I did
  • I learned how to keep strict boundaries between the business and my personal life
  • I learned how to create systems which enable me to carefully measure and track everything going on in the practice in 10 minutes a week
  • I learned how to stop thinking I was the only one who could do a task, and I began delegating without needing to micro-manage everything
  • I learned the importance of group morale, and how to keep it positive

Now I have 22 clinicians in my practice, working in three locations, supported by 3 office staff. Our practice generates an average of 130 referrals a month, and every month I make more money in passive income than I used to make in a month of full private practice. The ride has definitely smoothed out.

If you’d like help in Creating a Group Practice, check out my program of the same name, which gives practitioners specific guidance to follow to avoid the many mistakes I made when building my Group Practice.

For more information contact us at: or (800) 940-0185.

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