You Can Provide Higher Quality Treatment, Work Fewer Hours and Make a Better Living


Szifra’s article is featured in the Massachusetts Association for Marriage & Family Therapy August 2012 Newsletter

by Szifra Birke

August 29, 2012

It is possible to offer highest quality treatment for your clients, earn an income that supports you and your family, and reduce your stress so that you can enjoy your time at work and your life outside work.

Over the last 20 years I’ve built three successful private practices. I was on several insurance panels; I was the go-to therapist for a couple of law enforcement EAPs, I used to see 20 or more clients a week; I worked for myself so I collected the entire fee. I was also discontent.

It was hard to give my clients the best I had when I was under pressure to keep my contact hours up. But if I kept my hours moderate, I didn’t make the living I needed to. In either case I still had to invest time and money struggling with the insurance companies for what I was due, and managing the stresses of waiting for reimbursements that were late and unreasonably low.

When I’d finally had enough, I took the time to strategize ways I could provide better quality treatment by seeing fewer clients, while at the same time increasing my net income enough to pay for college for my sons. With some prodding and mentoring from people who believed I wasn’t valuing myself at the level I was worth, I created a practice model that has worked for me and for my clients. I’ve learned a lot in the process and feel privileged to help other clinicians make changes that enhance the quality of their work and lives.

I’m a person who loves a bargain, clips coupons and am definitely a product of my Holocaust survivor mother and father whose mantras included injunctions like, “Never pay retail.” (“Only monkeys pay retail” was my dad’s exact quote). To shift my own money rigidities into a rational pricing policy and a reasonable client-load expectation, I needed to delve into my emotions around money and get coaching help from professionals who were comfortable thinking about and dealing with wealthy individuals and families.

My goals were to practice at the highest level of compassion and competency that I was capable of, to serve both those with substantial means and those of limited resources, to have the energy and time to be the best mother and wife I could be, and to make a living that allowed me to save adequately for retirement, educate my sons and live a modest, but comfortable life.

I started my journey 15 years ago. Today I make the living I want and give my clients the best I have. Here are a few of the ways to make it work, some of the common pitfalls and how I got there.

First: Don’t set your goals too low:
  • You can get paid much more for your work.
  • You can set a schedule that allows you to see the number of clients that works best for you and for them and still make a better living.
  • You can choose to see the same number of clients you currently are and increase your income significantly, or see fewer and still make a higher income.
  • You can deliver the quality of treatment that you got into the profession to provide.
  • You can be more relaxed, more positive and have the time to grow personally and professionally.
Next: Realize that you may need to change your thinking
  • The economy is a factor, but not the major one.
  • The balance of your client demographics may need to adjust some.
  • You will need to expand beyond a fee-for-service position.
  • Your own attitudes toward money will need to be explored and probably fine-tuned.
  • Changes, like giving up insurance panels, can be frightening and should be approached thoughtfully.
  • An experienced coach who has been there can significantly ease the process of change by supporting you emotionally, sharing practice-tested ideas and solving idiosyncratic issues.
Understand your emotional relationship to money

It makes a big difference to the success of transitioning your practice if you invest the time to truly understand the nuances of your personal emotions around money. As therapists we all know the power of family experiences to influence present attitudes, but few of us appreciate the effect of our own money assumptions and emotions on our practices.

A few years after I started discussing money feelings and concerns with my clients, I realized that there were people I was still uncomfortable talking with about raising my fees. After spending some time reviewing what might be in my way, I recognized that my clients’ perceptions of me as overly focused on the money really bothered me.

The next Monday morning I saw Jack, one of my few cash-paying clients and someone who liked 90 minute meetings. Taking my fear in hand, and with the calm outward demeanor I’d been practicing, I announced, “I will be raising my fees in January. Our extended sessions will be $225 instead of the current $195.” He paused and looked a bit blank. Then he repeated back to me “So the session will be $225 instead of $195?”

Fighting the urge to explain I answered, “Yes. That’s right.”

“$225?” he repeated and hesitated again.

I had a swarm of thoughts running around behind my neutral expression. Take a second right now to consider what you might have assumed. My projections/stories of what he was thinking included:

  • “I can’t afford that.”
  • “She’s greedy and focused on the money.”
  • “Maybe it’s time to leave therapy or cut back to every other week.”

Setting aside what Jack may have been thinking, many of you may be wondering how I could even justify such a fee. At the time it was a stretch for me to consider it, let alone ask for it. Now I understand that it was not only a justifiable representation of my experience and training, but most clients’ reactions confirmed that it realistically represented my value to them.

In the face of Jack’s long hesitation I used all my “just-stay-still” strategies – slowly counting and then repeating to myself, “Wait, just breathe”. I was determined not to jump in and give any explanation unless he asked. The old me would have avoided this discomfort by not raising my fee, or would have jumped in to offer a reduction at his first pause.

His face brightened, “Oh, good!” That will make it much easier to count out.”

My money “stuff” just barely gave my client the room to have his emotions be the central focus. I was relieved— and I was humbled at how much work I had left to do to get comfortable with my money-related feelings.

Weaning your practice from insurance subsistence wages and paperwork

I began my transition to the practice I wanted by first dropping one insurance company. I decided that the one that drove me the most nuts just had to go. I couldn’t really afford to lose the income, but I knew that the move would encourage me – actually even then I knew it would force me – to raise my fees to a level comparable to others with my training and experience.

It also compelled me to practice what I was going to say to prospective clients who called and had that insurance. Initially I wimped out and referred out any new clients on that insurance without ever discussing whether they would be interested paying out-of-pocket to see me. As you can imagine, my colleagues benefited greatly from my discomfort!

At some point I realized that I was doing these potential clients a disservice by not checking with them and giving them a choice. I vividly remember my surprise on one of my early forays into this new, braver conversation and the man on the phone saying, “Oh that’s okay, I was referred to you and I’d like to see you.” Another one left me stammering when he said, “Oh, that’s all you charge?” I was rapidly learning that my projections and assumptions were seriously faulty.

My courage developed quickly and within approximately 18 months I was off all insurance panels. I needed to do some extra marketing as a price for being paid 50-100% more than what I was previously earning with each full-fee client. I always have the independence to lower my fee when I want to support a particular client in a tough situation; and in fact, I feel more able to offer reductions now that I am earning a reasonable wage. (I understand the ethics involved in sliding fees and have found a way to do this ethically).

Some of my coaching clients explore the fee-raising process and their feelings by raising their rate as little as five or ten dollars, which stretches them a little bit, and gives them a chance to see how it feels. Some of these clients inch their way forward, quoting a higher fee to future prospective clients until they find a fee that is comfortable and reasonable. I’ve seen therapists walk in the door saying they are comfortable with $90/hour and leave less than 60-90 minutes later comfortable with $125, and others starting with $115 who left charging $140.

If you’re beginning to squirm at all this talk of money versus doing good for our clients, it’s worth reminding yourself that we are providing a service that deserves compensation and that we will be more likely to provide the excellent quality our clients deserve if our mortgage is paid, our children are taken care of, we have adequate retirement funds and if we can afford time off to recover and heal.

  • Understand your relationship to money and professional fees.
  • Understand how humans shy away from potential loss even in the face of extremely favorable odds – short-term lower income with promise of dramatic increases.
  • Learn how those with wealth may think, feel and evaluate purchases and services.
  • Develop strategies to hedge your bets as you move from insurance to private pay.
  • Create scripts to present and respond to financial issues with potential clients.
  • Create a policy for yourself to help decide who you want to support with reduced fees and a script to clarify how to present that option.
  • Consider making an investment in coaching to ease the transition to a new practice model.
  • Set goals for how you will take advantage of reducing your stress and increasing your income.

For the past fifteen years, Szifra—pronounced Shifra—has been one of only a handful of professionals working at the intersection of the emotions surrounding wealth and transitions. She works with therapists who want to build or change their practices, wealthy families and their advisors, consults with service professionals, and offers presentations to professionals and their clients.

Szifra is the founder of Birke Consulting in Chelmsford, Massachusetts. She has received national print, broadcast and internet attention for her forward-looking work in family wealth consulting, success that is grounded in her 30 years of experience with change and general behavioral health.

Szifra is the author of Together We Heal, has been recognized by PBS’ Bill Moyers, and has been featured in books, national magazines, newspapers and television including The Psychology of Wealth, Business Week, Investment News, Dow Jones newswire, the Christian Science Monitor, and the Boston Globe. Szifra is producer and co-host of “Shrink Rap,” a syndicated cable TV show broadcast since 1997.