Over my consulting career with mental health professionals at various stages of their development, I have offered critical guidance about the development and maintenance of their private practices. I have also learned a great deal about why so many of them struggle in these efforts.


All of us who see clients privately have likely heard stories about why some left treatment and came to us, or why they did not return to the former psychotherapist. In the process, we have also hopefully learned why we were chosen to be their therapist as opposed to others with whom they have consulted.

Successfully Managing Telephone Contact with Clients

There are many ways in which clinicians — often unknowingly — defeat their own interests in the course of building and maintaining their private practices. One of these is the difficulty managing and handling telephone contact with prospective clients. New clients who were given several names of therapists have reported to me that one of the reasons they came to see me was that I was the only one who returned their phone call, or that I returned their call on the same day, rather than two, three, or more days later. I am astonished every time I hear this.

Another familiar comment I’ve fielded surround concerns the “phone-side manner” of the therapist who does return the call: “Unfriendly,” “Cold,” “Abrupt,” “I felt like I was bothering them,” “Didn’t really seem to want to answer my questions,” “She sounded to me like I must sound to the salesperson who calls me at dinnertime,” and more. It seems that some therapists are not any more comfortable talking with strangers than prospective clients are comfortable talking with us.

Prospective clients who have been sent to us by a known referral source may simply be calling to make an appointment as instructed. For many others, however, that initial phone call is a fragile moment that may have been delayed for some time. This is a first opportunity to engage the client and establish a positive initial connection. Many prospective clients who feel uncomfortable or even put off during the first call will never make it to the first visit with that clinician. Some potential clients call to arrange an appointment and save their many questions for the first visit.

Other prospective clients, especially those who are ambivalent, fearful, or who are seeking help under duress, require answers to their questions on the phone before ever coming in for a session. How this conversation is handled by the therapist might well make the difference between a new client and a non-client. If a therapist is uncomfortable with a prospective client needing a lot of information during the first contact, it might be evident and affect the quality of the encounter. Some callers ask difficult questions that must be handled sensitively, e.g. “What is your fee?” “What is your orientation?” “How long will it take?” “Should I bring my spouse?” And my favorite: “Now that I’ve told you a little about my problem, do you think you can help me?”

Many therapists seem to struggle in answering questions about their fee. There is probably no really safe or “good” answer — at least on the phone, and especially for clients who have issues or conflicts about paying for psychotherapy. Some therapists try to dodge the question by saying that they do not discuss fees on the phone and attempt to postpone the fee discussion until the client agrees to come in. The caller may find this answer evasive and permanently end the encounter. With a direct answer, arguably a superior response, the therapist runs the risk of an abrupt end to the encounter. The prospective client may be comparison shopping and the stated fee may eliminate a therapist right away or the client may make an appointment and then not show up.

It is important to remember and utilize the “rules of engagement” we all learned many years ago. The first phone contact is, possibly, the beginning of treatment. It is essential that the clinician is attentive, receptive, steady, ready to be of service, and generous so that the person contemplating therapy feels recognized and accepted sympathetically as a person in trouble.

I have always conducted the first session as a courtesy, i.e., no fee. This, I believe, accomplishes a few ends. For one, it conveys that the possible treatment is not all about money — especially helpful to therapy “virgins” who have seen too many Woody Allen movies. Second, if, for whatever reason the relationship is not going forward, there is nothing owed for what will not be an ongoing experience; and third, if I choose not to accept an individual as a new client in my practice, they are relieved of having to pay to hear me decline and explain why.

The Importance of Client-Centered Office Space

Some therapists are not sufficiently mindful of the impact that their office — their physical space — has on their clients and what that space conveys, especially new clients. One client told me that the main reason she elected not to work with someone with whom she had consulted, “There was a large spring protruding from the couch I was invited to sit on. The couch was in terrible disrepair and so was I. I was afraid that the broken couch might be a metaphor of some kind, so I decided not to go back.” Another oft-heard complaint concerns inadequate soundproofing, and, in the case of some home offices, too many personal distractions that interfere with a sense of privacy and optimal concentration.

Some clients have spoken of their confusion and upset about not having been given clear instructions about how to locate the office and, once there, which door to enter, whether to ring the bell, and what to do when the therapist may be running late and does not immediately respond to their arrival. Sometimes the issues that we see as insignificant have a profound impact on our clients. If one agrees that a first session is often a particularly anxiety-arousing event with a more-than-likely vulnerable prospective client, then therapists should do everything possible to ensure that the journey from phone contact to first visit is as smooth and reassuring as possible.

The office bathroom can be another problem area. Client observations have included such things as broken toilets, no toilet paper, general hygienic neglect, and broken locks or no locks at all to ensure privacy. To some clients, some of these things may be hardly noticed, but to others, these moments have significant impact and may influence or determine their feelings about continuing the relationship itself. This is generally more of an issue with new clients. If one agrees that the therapeutic cathexis is likely to be to the office as well as the clinician, then appreciating the importance of an attractive, appealing, “holding (office) environment” is crucial.

Tips for Communicating with Referral Sources

One of the most common complaints I hear from those who consult with me for private practice help is that certain referral sources have stopped sending clients for reasons unclear or unknown. Curiously, some private practitioners resign themselves to the loss and quietly regret it without ever inquiring why.

Referral sources expect to be acknowledged and thanked when they send a client to your practice. They also like to be informed about the disposition of their referral and some appropriate and discreet information about how the person they sent to you is doing. When I was building my practice many years ago, I sent referral sources a one-page statement entitled, “My Treatment Approach,” (see addendum to this article) which enabled them to understand how I conduct the initial evaluation and what the client would be experiencing when they came to see me. Feedback over the years was quite positive. Some referral sources sent work my way citing this document as unlike anything they had ever received from a psychotherapist marketing a practice. I also sent referral sources articles that I had written, kept them abreast of changes to my practice. In this way, I maintained contact with them if they were considering sending a new client my way. When I have not received any referrals from a traditionally active referrer, I inquire why. Sometimes the answer is as simple as, “you just didn’t come to mind,” so my call or e-mail inquiry served to reestablish my presence.

How to Handle Termination

The problem for many clinicians here, it seems, is when a client announces a desire to end the treatment when they are ready, and their therapist is not. This is an unfortunately mishandled moment in many treatment relationships that often sours or ruptures the relationship — at times, irreparably. Some clinicians simply cannot let go and, rather than explore the client’s desire to terminate as the treatment issue it is, they wind up angrily challenging the client and becoming an adversary, rather than remaining a valuable ally. This sometimes leads to an abrupt severing of the relationship and the client will not return. He or she may seek a new therapist or, worse, may be reluctant to seek therapy again.

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We are all very busy mental health professionals who, at times, run the risk of losing sight of the issues that have impact on our clients. Our interpersonal skills and sensitivity to client needs must go beyond the essence of the therapeutic contract. Attention to the areas of practice discussed above and the ways in which we represent ourselves has significant impact on the treatment and demonstrate respect and appreciation for the people in distress who have chosen to share their lives with us.

Addendum: My Treatment Approach

After making empathic contact, I conduct a mental status examination to arrive at as comprehensive an evaluation as possible in the initial hour. I assess motivation, capacity for insight, flexibility, frustration tolerance along with an understanding of the presenting problem and symptom constellation. I attempt to see how affects are handled, thoughts are presented, what mood is prevalent, and how well or poorly I am related to. Resistances are initially bypassed while attempting to ease the person into the therapeutic encounter.

I arrive at a psychotherapeutic diagnosis and develop a preliminary formulation of the goals of continued work. This formulation includes an understanding of what a person is seeking in his life and what seems to be blocking his or her progress and achievement. An informal “contract” is negotiated which serves as a blueprint for the therapeutic work ahead. There is early interpretation of the transference, where appropriate.

The above is done to determine whether interventive efforts should be directed at nurturing, maintaining, enhancing, or modifying inner capacities; mobilizing, improving, or changing environmental conditions; or improving the fit between inner capacities and external circumstances.

Questions for Thought and Discussion

Which of the author’s suggestions resonates most strongly with you? Not at all?

Which of his observations have you struggled with in your own practice development?

Identify three changes you can make to enhance your practice


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