Many of y’all know that I have been using TherapyNotes as our practice EHR for over 10 years now. I’ve looked at others and I just keep coming back to therapy notes because they do it all. If you’re interested in an EHR for your practice, you can get two free months of TherapyNotes by going to thetestingpsychologist.com/therapynotes and enter the code testing.
This episode is brought to you by PAR.
The new PAR training platform is now available and is the new home for PARtalks webinars, as well as on-demand learning and product training. Learn more at parinc.com\resources\par-training.
Hey everyone. Welcome back to The Testing Psychologist. [00:01:00] In April of 2024, I said goodbye to about 20 clinicians and staff for my practice. Today, I’m sharing what led to that decision to scale down instead of scaling up, which is I think the hardest decision of my professional career.
Let’s get into it.
All right, everyone, like I said in the intro, I made a big decision in the spring of 2024 to scale down my practice from about 40 clinicians and staff to our current state of 18 clinicians and staff. I essentially eliminated counseling as a service line in our practice and chose to pivot back to only doing testing. [00:02:00] For people who were very close to me, this was not a huge surprise, but to folks just outside the innermost circle, I think it was.
I’ve wrestled with whether to share the story and decision-making process here on the podcast, but the feedback from people I have told so far has been positive. I’ve learned that there are many practice owners out there who are considering a similar move. I hope that maybe some elements from my experience might be helpful if you are also considering a change in your practice or your life.
First off, I have to say this was probably the most humbling experience that I’ve ever had. For better or for worse, I can generally do what I want to do and accomplish the things that I set out to accomplish. I recognize the privilege in that, but I am used to being relatively [00:03:00] successful. If I work hard, I can generally get things done that I want to get done. I am used to being bright enough or athletic enough or whatever enough to reach the goals that I set.
But through this process, I had to come to terms with the reality that I was simply not skilled enough as a leader or director to guide our practice through a very challenging period of growth. I think that it’s challenging for many practice owners from what I hear and see. There are a lot of factors and people involved, of course. It wasn’t just me, but in the end, this was incredibly humbling. I had to come to terms with the fact that I didn’t make the right decisions over the last couple of years to help us scale successfully, or at least scale in a way that felt sustainable for myself and our [00:04:00] employees.
I think this is a tough chasm to leap for a lot of businesses when you hit that point of I think it is around 30, 40 employees where you have to make that choice of, are we scaling big and going all in on leadership, hierarchy, policies and rules and procedures, or are you going to stay relatively small and continue to operate as a more close-knit business.
I will give some history and context to show you what I mean when I say that there were some decision points over the years, looking back that I think could have gone differently. And then ultimately, I’ll talk about what it’s like to be here now and the rest of the process.
Going way back, I think, COVID was such a blessing and a curse to us. Like [00:05:00] so many other practice practices out there, we grew substantially. It was exciting and it was really easy. We spent no money on marketing because referrals were just coming in left and right. We opened a second location in a pediatric primary care office and added 5 additional practitioners in under a year from March 2020 to January 2021.
Looking back though, I think this was honestly the beginning of the end, so to speak. This was the first big leap from a leadership standpoint that I don’t think I did well. Managing two locations was almost immediately hard. I had trouble creating the same culture in the second location that we had built at our main office. Our main office clinicians were questioning why we needed the second location. They didn’t understand why we were putting so much energy into it. Everyone got along well, but this is the first time that folks, I think, started to question my [00:06:00] decisions as our director and I didn’t share the information in a way that was compelling or reassuring to them. I could tell them my rationale for adding that second location didn’t make sense.
We eventually, I thought moved past it and settled into the two locations set up, but looking back, I think I could have done a much better job integrating the two sites, explaining the rationale for adding the second site, listening to their concerns, and honestly, changing course if needed, but I had a plan, I stuck to it, and for better, for worse, that was the course that we took.
Now, as we grew, it became clear that I could not handle all of the leadership tasks in our practice. I had a fabulous assistant Director who had been with me for a long time, but in 2021 people in our practice were begging me to create more of a leadership team and let other people handle important tasks so that I wasn’t creating such a bottleneck in our [00:07:00] practice.
And this is when we embarked on the EOS journey, which is pretty well chronicled in my podcast series with that same name. I love EOS as a system and have kept many of the principles in place through our right-sizing process, but Implementing EOS was very challenging looking back.
First off, we had to choose a leadership team. There are only so many spots on the team. They recommend that you keep your leadership team to 3 to 5 individuals. At that point, there was one of our clinicians who was pretty upset at not being included. That person soon announced their departure from our practice. That was the first long-term employee to take off on their own.
While creating a leadership team was necessary and helpful in many ways, it started us down the path of inherently creating a hierarchy that wasn’t present before. And I think a better [00:08:00] leader could have handled this change more effectively both by talking with folks about it, managing the process, talking with the individual who was upset, but I was caught up in the excitement of becoming “a real business”. That’s certainly what it feels like to implement something like EOS. It felt like we were doing the right thing and it was exciting. The promises were really attractive and very helpful in many ways, but I think the missing piece from that was change management. EOS will tell you what to do and how to do it, but it does not address the ripples and waves in some cases that it will create in your business when you make big changes.
With this hierarchy came performance evaluations and a sticky dynamic of friends managing friends, myself included [00:09:00] as people were promoted, so to speak. It also introduced the idea of promotions and many upsides. I think there was also a dark side though, when one person gets promoted, someone else doesn’t.
All this to say the introduction of EOS with the leadership team, the structure, the accountability, the goals, the values, it was a lot of change all at once that introduced a bunch of new variables into our practice, which meant that our employees had a veritable buffet of circumstances to react positively or not so positively to. Through it all, I kept powering through sticking to the plan and assuming that folks would feel better with time. Now, again, I wish I would have made more space for discussion, change management, and processing with the staff because I think it became clear soon enough that [00:10:00] resentment or discontent was growing.
Fast forward, 12 to 18 months, and now we’re in probably the spring or summer of 2023. We had peaked at over 40 clinicians and staff, which was a fact that I think like a lot of you, maybe I’m projecting, I’m probably projecting, a fact that I was carrying around with a lot of pride because growth is everything, right? The number of employees and top-line revenue. These are the things we pay attention to. These are badges of business ownership pride.
I got a lot of recognition for that in our community and elsewhere. When you tell people you’re running a practice of 40 people, there’s a look that comes over their faces. I’m embarrassed/ashamed to say that that was very affirming.
By this time, our leadership team had grown [00:11:00] to include me as our director, visionary, our assistant director, admin and finance director, counseling director, and assessment director. Then we had second-tier coordinators under each director and clinical supervisors under the coordinators and we were just working so hard as a team to find all the gaps in our policies, procedures, HR stuff, and compensation structure. It felt really good. We were growing. The team was growing. We were solving so many problems.
We introduced a salary structure to provide more consistency to clinicians and more predictability for payroll. We’re still on salary, by the way, I think that’s been a good model. On paper, everything seemed good and headed in the right direction there in the summer of 2023.
But again, looking back, I could have done a lot more to manage through the changes. Salary in particular was a [00:12:00] tough change to implement. We thought that we were doing a good thing. I know in some cases, companies institute salaries to have people work more and not get paid for the hours, but we structured it in a way that was as close to the hourly model as possible, where we did a base salary that was contingent on a certain number of weekly billed hours, but then we did a quarterly commission for any extra hours that were worked beyond the base hours. So all the hours were accounted for somehow, but folks had a lot of questions and understandably at times it seemed almost suspicious of the change- like the leadership team was trying to take advantage of them.
This is one of the first times that I remember a thought popping into my head that went something like, we’re doing the best that we can and think we have everyone’s best interest in mind, but it’s [00:13:00] not enough. What will it take from the leadership team to do this the right way?
And now this is a moment of transparency for me. This dynamic of not being able to do things right despite my best intentions. This is a deeply held script or belief. It came up in my family of origin. It came up in my romantic relationships, my marriage. I absolutely own my part in this. This is a button for me. Others on the leadership team, I think we’re feeling similarly, but either way, this is a clear teaching moment that for me, again, that hard work and good intentions were definitely not enough to be successful in this particular aspect of business. Again, the change management part and the making room for feelings, dissent, and questions, right?
[00:14:00] Another part of the salary transition was that folks all of a sudden were accountable for a certain number of clinical hours each week. So this put more pressure on them to retain clients, more pressure on the admin team to fill their spots, and introduced the idea that the leadership team was keeping track of people’s work much more closely. This created a weird dynamic. People were anxious about meeting hours and they were also very vigilant about being paid for every hour that they were working, understandably.If I could do it again, I don’t know if a salary model makes sense, especially for therapists who are mostly used to an hourly model of compensation. I think salary works well for testing folks because it’s more predictable and you’re booking more hours at once in a sense, but therapists were more prone to cancellations and caseload fluctuations with the seasons. That was really hard [00:15:00] to navigate through that and design a salary structure that made sense, was reassuring and secure for them.
All that said, we were still, I think, optimistic as a team and a practice in the summer of 2023. We were moving right along. We had hired some great staff. We were sticking to EOS. There were all these issues to solve and policies to tweak, but it felt like we were running a real business.
And then came Crafted Practice in early August of 2023. For those who don’t know, this was my in-person business coaching event for testing psychologists. It was a four-day event with small groups and speakers, downtime, relaxing, business development. This event was so fun. I came back from Crafted Practice last year, completely on fire for the consulting work, particularly [00:16:00] for hosting these in-person events. It was the most fun, rewarding, enriching professional experience that I had had in a long time. Most importantly for this podcast conversation, it presented a stark contrast to running the practice. It reintroduced me to the idea that work could be fun, rewarding, and even easy all at the same time. It felt like, honestly, how my practice used to feel.
I came back from the event and met with my accountability group, two other group practice owners who I’ve met with for years. They’re incredible. And they were like, Oh my gosh, dude, you are glowing. My wife said the same thing. This was notable.
Why am I telling you this? Because again, it introduced the idea that work didn’t have to be quite so hard. I didn’t realize it at the time, but [00:17:00] running such a large practice had become relatively tough and stressful. We were doing good work and I had a great leadership team and a great staff. Everybody here was great, but it was hard. We had great people and there were at the same time always people problems per se to work through that ranged from small to really big. So even with this seemingly clear message, hindsight is always 20, 20. I was getting this message from the universe and people close to me. It took a few months to even consider any kind of a different path.
I was so locked into making the practice work because to do anything different in my mind would mean that I had failed. I had failed at growing this practice. I’d failed at being a leader. I had failed my employees, my team, and I had a really hard time seeing past that all-or-nothing view. [00:18:00] It was either keep growing and getting bigger or it was a complete waste of time and a complete failure. And the last several years were just wiped off the map. This fear of failure and inability to see it as anything different kept me, I think, paralyzed for quite a while.
But then in winter and spring of 2024, things really started to accelerate for a few reasons. The first is that I did a think week, which I’ve talked about here on the podcast before, in December of 2023. I didn’t actually do any work. I just meditated, not really, I don’t meditate, but did a lot of thinking, walking, running, sitting beside a lake reading. I did a lot of thinking about the practice and my work life [00:19:00] and my personal life to try and get some clarity on what was going well and what wasn’t going so well. I started to dive into some of those questions that I brought up in the podcast two weeks ago of what would this look like if it were fun? What would this look like if it were easy? What am I enduring that I don’t necessarily have to? This think week started a snowball rolling slowly downhill that would pick up speed really quickly over the next few months.
Let’s take a break to hear from a featured partner.
Y’all know that I love TherapyNotes, but I am not the only one. They have a 4. 9 out of 5 star rating on trustpilot.com and Google, which makes them the number one rated Electronic Health Record system available for mental health folks today. They make billing, scheduling, notetaking and telehealth all incredibly easy. They also offer [00:20:00] custom forms that you can send through the portal. For all the prescribers out there, TherapyNotes is proudly offering ePrescribe as well. And maybe the most important thing for me is that they have live telephone support seven days a week so you can actually talk to a real person in a timely manner.
If you’re trying to switch from another EHR, the transition is incredibly easy. They’ll import your demographic data free of charge so you can get going right away. So if you’re curious or you want to switch or you need a new EHR, try TherapyNotes for two months absolutely free. You can go to thetestingpsychologist.com/therapynotes and enter the code “testing”. Again, totally free, no strings attached. Check it out and see why everyone is switching to TherapyNotes.
I’m excited to tell you about PAR’s all-new PAR training platform, an elevated online learning environment with everything you need in one place. This is the new home for PARtalks [00:21:00] webinars, many of which offer APA and NASP-approved CEs and also houses on-demand learning tools and PAR product training resources. Best of all, it is free. Totally free. To learn more, visit parinc.com\resources\par-training.
All right, let’s get back to the podcast.
Another thing that happened right around that time was that we had a relatively major people problem in our practice that was super stressful. I’m purposefully keeping the details vague, but suffice it to say, it was really difficult to work through that.
And then as time went on, this feeling of what more can we do for our staff intensified and was capped by a pretty pointed experience in, I [00:22:00] think it was February of 2024. Myself and the leadership team had just put a lot of effort into communicating with our staff over the last few weeks. We held a retreat for the testing team to talk about practice issues, made a lot of space for discussions, invited feedback, and from our perspective, generally poured into the team to try and rebuild some of that trust and connection.
Along the way, we were having people fill out a feedback form twice a month just to check in, and get their feedback on how the practice is going, their work experience, and that sort of thing. Immediately after all of these efforts to try and reconnect and rebuild with our staff and like I said, putting a lot of energy into that, we got one of [00:23:00] those bi-monthly feedback forms back and someone wrote, “I have zero trust in our leadership team.” And even saying it right now, it still carries a lot of weight. It was a true gut punch in that moment after all of our efforts.
It’s hard to talk about this. I fully recognize that people have different experiences and perceptions and so forth and they’re absolutely entitled to share their feedback and that’s what it’s for. Looking back again, it was just tough. It was just really tough to be trying hard as a leadership team and to get that feedback.
But out of everything, the most important piece [00:24:00] in this whole puzzle was a trip to visit my parents in early March of 2024. This was about six months ago now. Something about this visit changed me. I can’t put my finger on why exactly, but during that visit, it suddenly became very clear that my parents were dying, they’re not actively dying or sick or ill or anything, but just the idea that they were getting older and they would not be around forever. They’re now over 70. My mom at particular has had a long road. She’s battled MS since her early 30s. And then she went through chemo last year for cancer. My dad’s had some health problems recently. And during that visit home, it really hit me that I could only have a few more good [00:25:00] years with them.
Whatever it was, once I let those thoughts actually sink in, confronted and embraced some of those thoughts, it opened the door to all sorts of existential existential angst. It was a short leap from there to recognize that I maybe have 4 to 5 good years with my kids before they move out. I have an 11 and 13 year old. I’m going to be 50 around that same time. And so on. This is what we go through. I finally realized and came to terms with what people have been dealing with since the beginning of time, which is that life is actually short. And this more than anything, just made me think really hard about how I was spending my time.
And so pretty [00:26:00] soon after I looked closely at nearly every part of my life, my marriage, which is thankfully amazing and solid, my time with the kids, my relationship with friends and family. Of course, it made me turn a close eye toward my work because I spent so much time and energy there. And within the work world, I spend the majority of my time working on my practice. So I looked at it very closely in this process. And once that door opened, that snowball from earlier really picked up speed. I dug into every aspect of the practice to evaluate whether it was easy, fun, fulfilling. During that process, I found out pretty quickly that counseling as a service line was creating a lot of the hardship in the practice, not my counselors by any means, but counseling as a service line.
For one thing, it wasn’t very profitable [00:27:00] because there is so much unbillable time for counseling like note writing, case management, follow-up, things like that. We pay people for that time, which I do not regret, but it is an unbillable time. It’s hard. For another, we built out so many leadership positions related to counseling that we were paying a ton of non-revenue generating hours to keep counseling going. So we had at that point, a counseling director, a group coordinator, site coordinators, and supervisors. It all added up. Most of our counselors were pretty experienced master’s level folks, which was awesome, but also expensive relative to what we were getting reimbursed.
The therapists themselves were also understandably more, I don’t know if critical is the right word, but vigilant about our compensation model. [00:28:00] With Hedway and Alma and SonderMind paying therapists over $100 an hour, I think they were always evaluating whether they were getting paid enough here and where the money was going and why it wasn’t more. And like I said earlier, the admin lift as well, just to keep counseling caseloads full, was a lot. It was causing a lot of stress for therapists and for the admin team.
So when all the data was in front of me, it was honestly a no-brainer. I needed to find some way to scale back the practice and focus on testing, and drop some insurance. But the huge hangup, of course, was the people. I loved my staff. I always have. I’ve always felt like we’ve had an amazing staff of good people and good clinicians and the thought of saying goodbye to them, in my mind, also disappointing them, running the risk that they might be mad at me, this was [00:29:00] brutal.
I also had to deal with a lot of identity issues in this process on who I would be if I was not the big practice owner in town. Those thoughts of failure were just going full force again. I second-guessed myself. I tried to find ways to keep everyone. I ran a million financial models, messed with the numbers and I got wrapped up in all the other details, like would we get out of our office leases? I was literally trying to find any reason not to make this decision and do it, but in the end, two things happened that pushed it over the edge for me.
One, I talked to my assistant director. She was incredibly supportive. She shared that she had been feeling burned out and unfulfilled as well, [00:30:00] which was validating. She was on board with trying to figure out a way to scale back.
The second was my accountability group that I mentioned earlier. Thank the Lord for them. If you all don’t have a good accountability group, please go find folks that you trust who can support you when you need it. But one of the other practice owners in my group was very direct and she said, you need to stop messing around. Pick a date, tell people ASAP, and figure out how to make it happen. She really held my feet to the fire. So I talked to my wife. She totally agreed. And at that point, I think just having permission and a firm date was all that I needed. And then it was just figuring out how to do it and what to say.
And so in mid-April of this year, I sat down and did about three days of individual conversations with all of [00:31:00] our therapists about this transition. We tried to give as long of a runway for both them and their clients to adjust and make new plans. So we set their last day as June 24th. This gave them two months to figure things out. I let them know that they could take all their clients with them and that we would support them in starting private practices. We would write letters of reference for any jobs they applied for. We would send clients their way if at all possible. Of course, the leadership team brainstormed how to handle any clients who needed referrals and we consulted with our attorney to make sure we weren’t treading into the world of client abandonment or anything like that.
I’m not going to lie and say that it went super well. Everyone was kind but there were definitely some tears and some upset feelings in the two weeks after the announcement. [00:32:00] And for someone who’s relatively conflict-averse and hates the idea of making people mad or not being liked, this was pretty tough.
From that point, it was a lot of logistics talking with our HR rep to make sure we were following appropriate procedures. She insisted on calling this a mass layoff, which killed me. I hate the sound of that. But that’s what she insisted we call it we were supporting staff and clients with the transition, all their questions and just planning for what the practice would look like afterward.
So where are we now?
If I am being honest, it is like night and day. The vibe among our staff is very positive. We are laser-focused on testing and doing the best that we possibly can for our clients. Our admin team [00:33:00] is more focused and pull in fewer directions and I have way fewer meetings on my schedule which is incredibly liberating and a lot less stressful. We’re also significantly more profitable so far, which doesn’t hurt.
There are still some hiccups, of course. The biggest one is that I currently have three office leases on the books because I haven’t been able to sublet them. Over the past eight years here in this building, we have gradually accumulated office suites here on this floor and we have way more space than we need because we all consolidated into the main suite. So I have three leases that I’m trying to get rid of. It’s substantial on the books. I’d like to get that taken care of soon. So that’s one thing.
I’ve also had to take back more tasks that were previously delegated to the leadership team.[00:34:00] And that’s fine. It’s actually forced me to get more efficient, utilize some new software to help out with different processes, and it’s generally very positive. I’m working with Fractional HR rep to handle the HR side of things. And that is a huge help and takes care of a lot of the minutiae that I otherwise don’t want to do.
I still have some lingering what ifs tied to the failure thing, which I haven’t totally made peace with. I do think I could have done things differently and ended up in a better place with a larger practice. But all in all, so far, two months in, I’m much happier, I’m more present with my staff, which I love. I’ve recognized, I think I’m a much better small staff leader than a large staff leader because I enjoy those one-on-one connections. It was really tough to grow and put more [00:35:00] layers between me and the staff. I’m more present with the folks that are here, more present with my family. I’m getting a lot more enjoyment from the work. I’m seeing more clients because I have the time and energy to do so. All in all, so far, so good.
To start to close, I have to say that it felt very self-indulgent to record this podcast. I am fully aware that this is not all about me which is tough. I’m not a spotlight kind of person and I’m certainly not a victim here by any means. It’s generally much easier to be the one making these decisions than the ones who have to live with them as employees.
That said, I’m sharing it because I think there are many folks out there wrestling with similar stuff. Like I said, I’ve had more and more conversations with folks over the last few months [00:36:00] as I’ve shared some of this and it seems like the more people I tell, the more come out of the woodwork to say that they are also somewhat unfulfilled, feeling discontent with practice ownership, really asking that question of, is this worth it to grow and grow and grow?
And so the hope is that some of you might be listening and let yourselves consider that possibility of doing something different that could be more enjoyable and in alignment with how you want to spend your life. Our practices can take over and become a machine that feels impossible to get out of or change, but you always have the choice to steer it in a different direction.
So if you’re considering a big change or recently made a big change, I’d love for you to reach out. Let me know. Tell me your story. It’s jeremy@thetestingpsychologist.com.
As always, thank you for listening. You can expect some updates over time as this new model evolves. In the meantime, I’ll leave you [00:37:00] with the questions from two episodes back. Those questions were, what would your practice look like if it were easy? Where are you having the most fun in your practice? What is the most fulfilling aspect of your work? Whatever you come up with, I hope that you can head toward those answers.
All right, y’all. Thank you so much for tuning into this episode. Always grateful to have you here. I hope that you take away some information that you can implement in your practice and in your life. Any resources that we mentioned during the episode will be listed in the show notes so make sure to check those out.
If you like what you hear on the podcast, I would be so grateful if you left a review on iTunes, Spotify, or wherever you listen to your podcasts.
If you’re a practice owner or aspiring practice owner, I’d invite you to check out The Testing Psychologist mastermind groups. I have mastermind groups at every stage of practice [00:38:00] development, beginner, intermediate, and advanced. We have homework. We have accountability. We have support. We have resources. These groups are amazing. We do a lot of work and a lot of connecting. If that sounds interesting to you, you can check out the details at thetestingpsychologist.com/consulting. You can sign up for a pre-group phone call and we will chat and figure out if a group could be a good fit for you. Thanks so much.
The information contained in this podcast and on The Testing Psychologist website are intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for [00:39:00] professional psychological, psychiatric, or medical advice, diagnosis, or treatment.
Please note that no doctor-patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host or guests of this podcast and that listeners of this podcast. If you need the qualified advice of any mental health practitioner or medical provider, please seek one in your area. Similarly, if you need supervision on clinical matters, please find a supervisor with expertise that fits your needs.