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  • 7 Lessons in 6 Years: A Rumination on Private Practice

    Six years ago, I walked to my mailbox, put in the key, and pulled out the mail just like every other day that I’ve walked to the mailbox, turned the key, and pulled out the mail. 

    Except this wasn’t every other day. This day, as I sifted through newsletters and bills and a ridiculous number of continuing education ads, I got a piece of mail from the State of Texas. And this piece of mail was my Certificate of Business Formation for Prism Counseling Services, LLC. I, Max Casero, was a business owner. Business Owner: those are some words I never thought I’d have behind my name.

    But here I am, and boy, what a wild six years it has been.

    So, on this, the sixth birthday of Prism, I’m feeling nostalgic and reflective about all the things I’ve learned as a therapist, small business owner, and person. Given that this blog is entitled “I’m Having a Thought,” this seems like an appropriate place to impart some of my biggest lessons.

    I’m long-winded, so here’s the summary:

    1. Trust your gut and your values.

    2. Stay open to possibility.

    3. Create the place or service you would actually use.

    4. Acknowledge when you’re in over your head, and find or hire help.

    5. Plan for any change to take 3-6 months longer than you want it to.

    6. Practice editing your vision.

    7. There’s always going to be more to do. Build boundaries around your time and effort.

    If you’ve got the time and space, read on to learn more. There are some great nuggets, I promise! And if this is the end of the road for today, thanks for reading along!

    1. Trust your gut and your values. As I’ve mentioned before, I have lots of feelings about the social and mental health gatekeeping involved in private pay-only therapy. When I started Prism, I was adamant that we accept insurance because professionally, I come from a place of seeing folks who needed services the most be turned away or fall through the cracks. Yes – insurance is the worst – like an even bigger headache than the worst migraine you’ve ever had. But it’s also a sustainable referral source and provides consistent income. So when COVID hit and other private practices were either shutting down or scrambling for clients, my rolls were growing so much that I went from a solo practice into a group practice of four within a year.

    2. Stay open to possibility. Throughout my professional life, I’ve wasted a lot of time ruminating about the things I was never going to be. Never a therapist, never in private practice, never owning a group practice…when in fact, those are the things I’m best at. The caveat was that I had to find a way to make each of those roles align with my values and to own them in a way that felt genuine to who I am as a person. Once I’d worked through the dissonance between how I thought things had to be and how I could make them, I was able to see the potential of what I was doing and to develop some tangible goals.

    3. Create the place or service you would actually use. I love Prism – and not because it’s something I’ve built (well, I do love it for that reason, but that’s not what I’m talking about here.) I love it because it’s person-centered. I love it because it acknowledges that the world is hard and working on your mental health can be a real slog and struggle. I am not a zen therapist; not one of my clients would accuse me of being cool, calm, or collected during session. I love vibrancy and color and just a little bit of chaos – and I believe people are sort of like that: vibrant, colorful, and chaotic. I love Prism because it acknowledges and honors the chaos – that people can feel dark and gloomy or like a buzzing swarm of anxiety bees and simultaneously be vibrant and hopeful and still find their breath. I love Prism because its goal is to acknowledge complete personhood and to meet folks wherever they are. That’s a service I would use.

    4. Acknowledge when you’re in over your head, and find or hire help. When I started Prism, I was doing it all: seeing 28 clients per week, applying for and managing all my credentialing, running all my billing. I was a solo practitioner machine. Then my partner and I had our first kid, which led to the first of many reevaluations about priorities and work – about how much I could hold emotionally on four hours of sleep with a newborn and about how being a full-time therapist impacted my ability to show up for my new little family. After a while, we got into a rhythm, and just when I thought I’d figured it out, COVID hit, and it was time for my biggest reevaluation yet. 

    I couldn’t ethically keep people on my waitlist for literal years. So the first thing I did was hire help in the form of new therapists. I grew my practice, and that placated my stress about an insurmountable waitlist. However, that expansion meant that my administrative responsibilities quadrupled – and frankly, those responsibilities were far more stressful than knowing folks were waiting for services. So I hired a different kind of help – people who specialized in credentialing and administration, and it was the best business decision I’ve ever made. By acknowledging that I can’t, in fact, do it all (and shouldn’t, because I made A LOT of mistakes) I made the first real capacity building investment in my business. With administrative and financial tasks under control, I could focus on providing quality therapy and better support for my team and family. Handing off specialized administrative responsibilities also created the emotional space I needed to think about moving Prism from a behavioral health model to an integrative health model, which is where we are currently headed.

    5. Plan for change to take 3-6 months longer than you want it to. It’s worth the wait. This is a lesson that I’ve learned over and over and over again – be it with parenting, working a treatment plan, or growing my business. The problem with any change is that no matter how hard you try, you can’t 100 percent control the pace, scope, or outcome. Even if it’s a change that you’re instigating, you’re still at the behest of your environment, systems and people, and let me tell you: the environment and systems – while meant to be efficient – are made by people, and people are downright inconvenient. To compensate, add three to six months to any timeline you’re creating. Here’s why:

    1. No change goes right the first attempt. This additional time gives you space to troubleshoot and problem solve any lingering issues that may arise. Failure is part of life and the space in which we learn things and make improvements. Use this time to learn. 

    2. Life happens and if you’re always running a tight timeline, inevitably, you’ll miss deadlines because stuff comes up. Frankly, the stress and frustration aren’t worth it.

    3. We live in a world that has grown accustomed to instant gratification. We want outcomes, and we want them yesterday. But that short-term solution may have detrimental longer term consequences. Adding three to six months gives you time to account for those impacts and to pivot if necessary.

    4. Similarly, adding time to an expected outcome gives you some space to engage in more creative problem solving. You’ve got longer to research, longer to ruminate on an issue, more time to meet with experts or consultants. The more information you gather, the more comprehensive the plan. So instead of working in fits and starts or making a change that requires a redo, you’ve given yourself time to work with paced creative intentionality.

    6. Practice editing your vision. As a human, I struggle to manage my expectations around the scope and pace of projects. I’ve got a vivid imagination and a belief that with enough time and effort, I can learn to do just about anything. This makes me a really good big picture person, but often, my initial plans are too elaborate to be practical in the timeframe I want them to happen. This is where editing comes in. 

    I never really let go of the whole vision because I use it as motivation. The vision is the dream that keeps me grinding through the monotony and frustration of growth; however, when it comes to business growth I’ve started using the following process:

    1. Write out the dream or vision or goal. Capture as many details as possible. Use your senses: what does it look like, sound like, smell like? What’s the energy like? Who’s there? What are they doing? What are you doing?

    2. Make a list of resources that you’ll need to fulfill the whole vision and create a budget based on those resources. It’s important to know how much it’s going to cost.

    3. Do a three-way prioritization:

      1. Weigh each of the parts from most important to least important to achieving the overall vision. What makes each aspect more or less important to the overall vision?

      2. Determine which parts of the vision you can implement now versus which ones will take significantly longer. Rank each part of the vision from easiest to most difficult or from fastest to most time/effort consuming. Remember to add three to six months for the more comprehensive changes.

      3. Rank each aspect of your goal based on financial feasibility. Which parts of the vision will cost you now, but make you money later? Which will make you money now, but might not be as profitable in the long run? Which is more important to you?

    4. Look at your lists and determine which aspects you need versus which ones you want. Rank them 1-3: 1 – need, 2 – helpful, but not totally necessary, 3 – want. Focus on the needs, and use the information from your three-way prioritization to create a timeline and task list. 

    5. Go forth and create, build, realize!

    6. Reassess in three months. You’ll likely find that many of your 2s and 3s have changed or fallen away, and you can adjust accordingly.

    7. There’s always going to be more to do. Build boundaries around your time and effort. We are not defined by what we can do, how much we get done, or what we create. Those all are expressions of who we are, but they are only a fraction of our whole self. The truth is, nothing is ever complete and we have to learn when to shut it down and come back tomorrow. Here are some questions to ask yourself if you struggle to know when stop or take a break:

    1. What’s your body feel like? When was the last time you ate or drank water or went to the bathroom?

    2. When was the last time you intentionally moved your body?

    3. How are you sleeping?

    4. What are you sacrificing to achieve this goal or vision?

    5. Who are you sacrificing to achieve this goal or vision?

    6. Why are you making those sacrifices?

    7. How is this goal or vision tied to your self worth? What would it mean if you failed?

    The lovely thing about having self-defined goals is that you get to define them: you decide the scope and the timeline, and so if they need to change, change them. Remember: you are more than what you produce or create. You’re a whole ass person who is doing awesome stuff everyday.

    Thank you for reading along. Thank you for supporting Prism – even if it’s just by making it to the end of this article. Here’s to many years to come!