Episode 79: Wealthy Therapists — Step Into the Boardroom of Your Private Practice [featuring Tiffany McLain]

Show Notes

There is a lot of shame talk in the therapist community around wanting to make money while helping people.

As a result, many therapists buy into the idea that they are meant to charge low and see many, but this isn't exactly ethical. If you look at this approach a bit closer, it's clear to see that therapists who live by trying to help as many people as possible at a low cost aren't able to give their clients the quality of care that they need to actually benefit from therapy, and many therapists in this position end up burning out and living in desperation.

If you have been struggling with how to help others and still put food on the table as well as how to run a private practice that is sustainable and really helps clients heal, this episode is for you.

In this episode, I talk with Tiffany McLain, a therapist, a clinical fee strategist for therapists in private practice, and owner of LEAN IN-MAKE BANK, INC.

Top 3 reasons to listen to the entire episode:

1. Understand why seeing more clients for less money can be unethical and cause more harm than good.
2. Identify why you might be telling yourself that wealthy therapists are "bad" and that you shouldn't make $250,000 a year seeing 15 clients a week.
3. Learn how you can help more people by seeing fewer clients and charging higher rates, and why that is OK.

It's not uncommon for therapists to tell themselves that the profession doesn't exist to make money, but as a private practice owner, you have to wear all the hats, therapist AND CEO, HR, etc. It can feel intimidating at first to accept that making money as a therapist isn't bad and you are allowed to thrive, but once you do, you'll find that you have more opportunities and capacity to help others and yourself.

More about Tiffany:

Tiffany McLain, LMFT is a clinical fee strategist for therapists in private practice. Her mantra is, “Full fees are the new black.” Via her program, The Lean In. MAKE BANK. Academy, she helps therapists ethically earn 30 to 50% more per month while seeing fewer clients by showing them how to think about and directly address fees in a clinically appropriate manner.

The Lean In. MAKE BANK. Academy is a program that addresses the underlying money mindset stories that keep therapists broke so they can become THAT therapist who charges premium fees and cash pay. With the LIMB 4-step framework to make BANK, regular coaching calls to help you go to the next level, a phenomenal community of funny and intelligent therapists, be ready get real raw and real rich. 

Check out Tiffany's Free Workshop, 4 Steps to Your Six-Figure Therapy Practice, to learn the 'secret' to building a six-figure therapy practice while seeing fewer than 15 clients a week.

Tiffany's Website: leaninmakebank.com

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A Thanks to Our 2 Sponsors: The Receptionist for iPad & Owl Practice!

The Receptionist for iPad:

I would also like to thank The Receptionist for iPad for sponsoring this episode.

As you prepare for the new year as a private practice owner, one area of your business where you might be able to level up your client experience is from the moment that they enter your office and check in with you. For many private practices, the client check-in process can be a bit awkward and confusing.

Clients often enter into an empty waiting room. And chances are you're wrapping up a session with someone else, so there's no way of knowing when they arrive. With a visitor management system like The Receptionist for iPad, you can provide clients with a discreet and secure way to check in for their appointment while instantly being notified of their arrival.

What's more, The Receptionist offers an iPad list check-in option where clients can scan a QR code to check in, which negates the need for you to buy an iPad and stand. Go to thereceptionist.com/privatepractice and sign up for a free 14-day trial. When you do, you'll get your first month free. And don't forget to ask about our iPad list check-in option.

Owl Practice:

I would also like to thank Owl Practice for sponsoring this episode.

Running your own practice is hard. With so many moving parts, it can sometimes feel overwhelming. That's where Owl Practice swoops in. Created specifically with mental health providers in mind, Owl offers a comprehensive HIPAA-compliant solution that helps you manage your practice in one convenient platform.

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Get started with Owl Practice today.

Transcript

PATRICK CASALE: Hey, everyone, you are listening to another episode of the All Things Private Practice Podcast. I'm your host, Patrick Casale, joined today by Tiffany McLain. She's an LMFT out in California and the founder of Lean In. MAKE BANK. A lot of you probably already know about Tiffany because you probably use her fee calculator, Hey Tiffany, a Lean In. MAKE BANK program. But today we are going to talk about money, and money wounds, and money narratives, and all things about money that kind of stir shit up. 

So, Tiffany, I'm really happy to have you on. I know you're busy and I know we've been trying to do this for almost two years.

TIFFANY McLAIN: So, thank you, Patrick. And for people who are listening, this happens to be a holiday, so to the point of being busy, I have two little children who are here at the house right now, so if you hear screaming, and crying, and kicking around, that is why.

PATRICK CASALE: That seems very entrepreneurial of like, "Hey, we're here, we're just pivoting, adapting, and this is our situation." My wife is downstairs with our erratic Shih Tzu trying to keep him quiet as well, so…

TIFFANY McLAIN: We're all on the same page, we're all together in this folks.

PATRICK CASALE: So, let's just dive right in because we were talking before we started recording and you're right, I wish we would have recorded that, but Lean In. MAKE BANK, how did this come to be? I'm sure you've told this story a million times, but I want to go deep with this. Like, money and therapy, and money and therapists stirs stuff up whether it be inner child wounds, whether it be just narratives around the helping profession. But tell me a little bit about how this came to be.

TIFFANY McLAIN: I will do that. And I will also say, I think it was last week I was talking to somebody who teaches people how to market using social media. And she's not a therapist, but she works primarily with therapists. And she made a comment that was something like, "Tiffany, you know, therapists, there is no other group of people who…" I don't know the exact language she used, but basically, they'll put up with so much. They'll just allow themselves to be in the most destitute of circumstances, and won't change, or don't even know it's a problem. 

And so, she said, "You know, I really love working with this population because I want them to know there's another way." And I said, "Really?" When I think of therapists I'm so… I was raised, you know, in the culture professionally, I'm surrounded by therapists, and so, really this idea of, we just sacrifice, and sacrifice, and martyr ourselves, and always last on the list of who gets taken care of, it's typically the therapist. 

And so, to hear that reflected by someone who's not in our profession was really striking to me, and it was a good reminder because again, it's the water we all swim in. So, for me, swimming in that water, even from the moment I went to grad school, I was in my interview to join a clinical psychology program and even then I knew that, ultimately, I wanted to have a private practice when I came out, be my own boss, have my own business. Like, that was an exciting thought to me. But I knew I couldn't say that. In the interview, I had to say, "Oh, maybe I'll just go to a nonprofit, or, you know, really, I just want to give back."

I knew I couldn't say the other part about… and I want to give back, and do good work, and make good money myself, and so, even from that beginning, I was aware almost outside of my conscious awareness that I can't talk about this. 

And so, I had some idea that I was going to have a private practice. But early on, I started having the beliefs of, okay, if I have a private practice, I have to have low fees because I have to give back and I can't have high fees because then I'm not truly doing good work, so let me create a whole nother online business on the side to subsidize the private practice that I'm building over here. So, that's how Lean In. MAKE BANK originally started. It was Hey Tiffany then, now Lean IN. MAKE BANK with the idea of I'm going to be seeing patients or clients for $30 per session forever so in order to actually reach my financial goals I need to have a whole nother business.

PATRICK CASALE: That's wild, isn't it? So, you're thinking about this at the same time of like, I'm going to have to subsidize therapy because people can't afford to pay for therapy, but I have to pay my bills and I have to live my life. So, how the fuck do I do that if I'm just working in private practice? 

And I think we've all been there with like interviews, like you're saying, where you don't really openly disclose your long-term goals of going into small business ownership and private practice. And I do think that a lot of this starts culturally, for our profession, in graduate school where you're kind of told over and over, "Hahaha, you don't get into this field to make money."

And that's kind of like a badge of honor, almost, of like, we're here to help, we're here to support, we're here to sacrifice. And that just seems to just lead to, as we know, with all helping professions, unbelievable amounts of burnout, and compassion fatigue, and the inability to stay in this profession because we're constantly putting everyone else's needs before our own.

TIFFANY McLAIN: That's absolutely right. And I'll argue, actually, I was surprised to find this, there was a woman in the 80s, her name was Ella Lasky, a psychotherapist, I think, a psychoanalyst. And she actually did a small study of psycho-analysts and found that it didn't start in grad school, but in fact, it started with our family of origin. Most therapists in their family of origin are the one who are positioned as the helper, they mediate the conflicts, they make sure everyone else's emotions are taken care of, highly attuned and so, we start out there getting our value by putting aside our own emotions and needs, and making sure other people are taken care of. 

And then, for many of us, women, people of color, we go out into the wider society, and we're continued to be told, "Your job is to serve first." For generations. And so, then, we have all of that, and then we go into grad school with our messages reinforced over and over and over. 

And then many of us, here's the thing that's exciting about therapists, for those of you listening, Patrick and I were talking about, wow, the unique experience of being a therapist, also trying to start a business, the fact that there are any therapists at all who decide to have their own business, decide I'm not going to go the agency route, or I'm not going to go purely the nonprofit route, I'm going to do something for myself, that also speaks to be able to spark the potential that we're willing, even after all of that training, and societal brainwashing, and professional brainwashing, we're going to still try to have this little thing for ourselves, which is our business, is hopeful, that is hopeful to me despite all the obstacles that come with trying to do that thing.

PATRICK CASALE: Yeah, absolutely. I think it instills a massive amount of hope. And I think you're seeing a shift in the therapist community where you're seeing more people go into private or group practice straight out of grad school instead of going down the agency route. 

And I know there's a lot of division in that thought process of like, you have to earn your stripes, and go to community mental health, and work with everybody, and burn yourself out to the point where you can finally build up the courage to put your fucking notice in and be replaced in three days, and then have to work that notice out, and then, you can be a successful private practice clinician. 

And that's just not true. But it's so ingrained, and it's so instilled that that is the only way to do things. And I think, for all the negative, and damage, and trauma, and destruction that COVID brought to our world, it also brought into perspective that people don't want to be treated that way anymore at jobs, where it was like, "You're going to make me come into the office during a pandemic, and see these clients that I can see online? Fuck this, I'm going to go work for myself." And I think you started to see the shift now with people saying like, this is the route I want to go and we're definitely seeing more entrepreneurial therapists.

TIFFANY McLAIN: It's really interesting that you say that. I wonder if it's true and I think there is a trend that more therapists are willing to go out and try their hand at private practice, try to create their own thing. And I also wonder if, you and I are seeing that more because we're in this, we're in it. 

And so, I'm still shocked when I have people emailing me and saying, "Well, Tiffany, I do have a private practice, but I could never get on to insurance because everyone in my area is on insurance and there's no one in my community who can do private pay." And I'm like, "What?" Because I'm so inundated in a different world. And we really encourage therapists to end up working with us to surround themselves with people who are willing to imagine therapists that there's a different way of doing things where you don't have to be abused by an employer, or you don't have to have an insurance company who's saying, "You know, you've seen that person more than 10 times, you know, are you sure you still need to be seeing them?" That we can actually create for ourselves an environment where we do the kind of work we want to do, and we make the kind of money we want to make. 

And once you first accept that that's possible, you then start looking out and seeing, "Oh, there are other people doing this too." But until you accept that it's possible, it's so easy to find so many therapists who are still in agencies or nonprofits working… I was going to say nine to five, but let's be real, like an eight to seven, and making no money and struggling.

PATRICK CASALE: And justifying it. And I think, right, like, it is an echo chamber when you start to surround yourself with people who are, obviously, attracted to being small business owners than the people that you're engaging with either are small business owners or want to become small business owners. You're not seeing the majority of the population that is working at a community mental health agency, nonprofit, etc. 

And listen, I've worked at nonprofits, I've worked in community mental health agencies, they need to exist, they do. Our systems are broken. Like, there are people who are disenfranchised, who just are never going to be able to access care any other way. But that doesn't mean that you have to spend the entirety of your career working for wages where you can't even pay your bills, or you have to go out and get a second job even though you have your Master's or PhD because you simply cannot afford to live.

TIFFANY McLAIN: I was emailing with somebody, a subscriber who emailed me the other day, and she said something about her wake-up call was when a friend of hers, who is a licensed therapist, also had to be on food stamps because they were working for a nonprofit and they felt guilt about the possibility of earning more than the people they were working with at the clinic, which in my mind, there's something deeply disturbing about doing all the work to become a licensed professional. You actually have the capacity and the education, and the support system to do very well both financially, but also make a big impact. 

And when we're so over-identified with the people we're here to serve, or even I would argue, parts of ourselves who we haven't been able to work through yet, we're really doing a disservice to the clients we're serving and the profession as a whole.

PATRICK CASALE: Yeah, no, that's really well said and I completely agree. And I know some of you listening are feeling a certain sort of way as we're talking about this stuff. Like, that's just the reality and I just encourage all of you to hear all sides of this conversation. 

And I think you're right. And I also think that a lot of us get into this profession at first to heal parts of ourselves through the work that we do. And if you don't do your own work while you're a helper, if you don't work through these inner child wounds, and these intergenerational wounds, and all of the narratives, then it's always going to feel like your work is simply connected to the work that you're doing, the progress that you're making, the outcomes that you're seeing. You don't get to pay the bills with any of that and it's also really unhealthy. It becomes this codependent narrative of, "My clients need me, I can't step away from my caseload, I can't go on vacation because they need me, they will not be successful without me."

And in my opinion, that is unhealthy. And I always go into these… when I was working as a clinician, going into these sessions thinking my first session is my first step to working myself out of a job. Like, I should be working myself out of this person's life, not figuring out ways to stay involved.

TIFFANY McLAIN: It's really interesting. So, I'm going to even have you back up. When you said some people might be feeling a certain kind of way, and some of the listeners, you all out there might be feeling a certain kind of way hearing us talk like this. 

So, Patrick, can you give me a sense, be the voice of our listeners for a minute, those ones who might be feeling a certain sort of way as you and I are talking about a different kind of professional life where we can be in private practice making 100, or 200, or $250,000 while seeing fewer than 15 clients a week, that's what we're not going about? What's the voice in the head of the people who are listening to us say there?

PATRICK CASALE: There's so much and number one is going to be the how could you do, right? There's so many people who don't have the resources or can't afford therapy, that therapy is a luxury. Number two is going to be, this is capitalist mentality, this is just feeding into the capitalist system that we all live in, regardless, of whether or not we want to conform to it or not. But number three is, "How could I ever possibly charge someone X amount of money if I don't have X amount of experience, or these licenses, or acronyms behind my name?" I hear that a lot with like, let's just use EMDR or IFS. 

You know, "I don't practice EMDR, I don't practice IFS, how could anyone ever afford to pay me?" More that I hear is, like you mentioned before, "I live in an area where everyone takes insurance, how could anyone afford to pay me out of pocket?" 

And a big one that I wanted to talk to you about and I emailed you about your comfort level around this is BIPOC folks and money. I, obviously, am as privileged as it gets as a cishet white man in America. However, a lot of my coaching clients are black women, and they will initially really struggle with the mindset of anybody is going to pay someone who looks like me, let alone anyone's going to pay me X amount of money for someone who looks like me. 

And I can't sit there and say, "Well, that's simply not true." Because, you know, I haven't experienced that. But I have helped so many women of color create these thriving private pay practices and it's really beautiful to witness the unburdening of like, holy shit, this is powerful. Like, people who look like me are seeking me out, and paying me my rate, and are staying around. And I just think that's a really powerful thing. But obviously, I'm not of the position to really speak to that. So, where do you want to start?

TIFFANY McLAIN: There's so many places we could start. But the first place I want to start is, first of all, [INDISCERNIBLE 00:15:51] it sounds like you're doing extraordinary work with your clients and that your clients are doing extraordinary work. 

So, the first thing I'm so curious about, what stands out to me is how interesting that these women of color, and let's say, black woman, in particular, are joining your program and getting permission from you, a cishet white guy, that this was possible for them. And I even wonder something about you saying some version of that allows them to go forth and try treading these seas or believe that it's possible for them. I'll stop there, what do you make of that dynamic?

PATRICK CASALE: It's one that I have to pay very close attention to because I also have to place myself in a situation, in someone's shoes where it's like, it's very easy for me to say go out and just do this, right? Like, it's been an easier road for me by far. But what I'm trying to do is show up and say, we can at least try to do this. You have the skills, you have the education, you have the training, you have the personality, you're showing up authentically, you're showing up as you, you understand your client's pain points, what they're looking for, let's really start working on this mindset because you're going to become a business owner and separating ourselves a little bit from the therapist only role because if you go into private practice you are a small business owner, whether you want to admit that or not, you are taking fee for service. 

So, trying really hard to work through those mental blocks and barriers while still acknowledging that there is a lot of disadvantaged and disenfranchisement, that's not a word, that lots of my clients being disenfranchised are multiply marginalized with lots of different identities, the recognition of there are people who look like you who are looking for you, there are people who look like you who can afford to pay you. But it really is about getting out of that mentality of like, the only people who come to therapy have Medicaid, are state-funded, or don't have money to pay for services. 

And that's overarching for a lot of new practitioners who come out of an agency job because that is all you've experienced in terms of who you've been supporting. So, it's very easy for your worldview and your lens to get really narrow, and say to yourself, these are the only people out there looking for help when in reality, we all know that that's not true.

TIFFANY McLAIN: That's right. So, it's really interesting what you're saying. Back to that idea of if we're surrounded by a particular reality, we at first can't even imagine something else. And then once we can imagine it, it's hard to believe that it can be true for somebody like us, whatever that like me or in my unique situation is. 

Back when you were listing a certain way a person might see or a therapist listening to this episode, you listed two categories. The first was, is it fair? Am I allowed… not am I allowed to, but is it ethical to charge premium fees or take care of myself financially when so many people need my help? That was one category. 

The other category was, okay, let's say I don't have any barriers to whether it's ethical or not. I know that it is, but would somebody actually pay me that? And so, I'm hearing, particularly, let's say, with black women, women of color, maybe people from the queer LGBTQ community. Actually, I think there's a difference, what I've seen with my students is, in certain populations or communities, it's a question of ethics, people need me and I need to be accessible. 

In other populations and this could be among race, or class, or culture, or gender, but it doesn't always fall along those lines. There's a question of, yeah, I really believe that it's okay to make a lot of money or to really take care of ourselves, but I don't believe someone's going to pay me that. 

So, there's something about the mindset of making sure both of those things are being addressed, accessibility, we live in a capitalist society, and who's going to pay me that? 

One of the things I'm thinking about is when there's a question of accessibility or capitalist society, I always come back to the therapist who's raising those points, who's in private practice, and saying you started a business, just like you were talking about Patrick, you started a business, you can go back to an agency, or a, you know, nonprofit, whatever the situation is, community mental health, and do that. But if you go into business for yourself, you're responsible not just, like you were saying, for the clients you're providing for, but also, you're responsible for taking care of a business, meaning you have to have a CEO hat, and you have to have an HR hat. And that HR person is there to take care of the therapist who provided the one-to-one service. 

So, I encourage therapists to step into their boardroom, internal boardroom, their committee, and have a conversation with the different board members, the HR department, the CEO, and the therapist all sit down at a table and look at the business finances together and make sure that the therapist has been taken care of as well as the clients.

PATRICK CASALE: I love that. And I'm doing a lot of IFS therapy right now on my own life, so that feels very IFS to me, like parts everywhere. 

TIFFANY McLAIN: Oh, yeah.

PATRICK CASALE: The thing I like about that is you get to really sit down with these different parts of the business, and really get involved, and really pay attention because I think too often we bury our heads in the sand when it comes to the money and the finances of our businesses. A lot of us don't even know what's coming in versus coming out. 

And money is a taboo topic for so many people. Maybe your parents didn't talk to you about money, maybe, you know, depending on circumstance growing up, you were raised in poverty, you didn't have access to it, you didn't have the means, but it's a topic that is taboo for a lot of people. So, I know so many therapists who just cannot get a handle on their books because they refuse to look at them because it's really intimidating and it brings up a lot of shame.

TIFFANY McLAIN: It is, oh, so yeah, I want to… well, two things, I want to first acknowledge and validate those feelings and therapists have them. It is terrifying for a lot of us. It does feel so lonely. And there is a lot of shame when we actually look at the reality of our financial situation. And anyone who's listening to this episode, whether you're working with Patrick, or you work with me, or you work with someone else, I do encourage you to go into a community where you can know that it's not a comfortable… I wouldn't say a safe space but the uncomfortable, but that you're going to not be judged, that you're going to have support with actually having somebody by your side or multiple people by your side who have been there, they understand exactly how scary it is and they've gotten to the other side, and they're willing to do it with you. 

I think we can't have private practice if we're trying to do it alone, which is really difficult if there's shame around the money stuff. That was- 

PATRICK CASALE: Oh, yeah.

TIFFANY McLAIN: …first thing, yeah, go ahead.

PATRICK CASALE: It's so hard to ask for help, or guidance, or mentorship, or support if you're in that shame space, where it's just like, I just can't talk about this because of how uncomfortable it makes me, and how shameful it makes me to talk about. And, you know, I think it's important in private practice, in group practice in this profession, in any helping profession, to have support, to have those positive support around you because it can feel so fucking isolating when you're in business ownership for yourself. You're like, like you said, the HR hat, the CEO hat, the therapist hat, sometimes you're in marketing hat. You know, like you're the one behind the scenes driving the ship. And there's only so much capacity, there's only so much energy to put out. 

So, that's another part of the money conversation, is there's only so much capacity as a solo practitioner. You only have so many hours, you only have so many slots, you only have so much energy before you can now be useful in your role. 

And I think it's really important to know that because I know how easy it is to get into mentality of like, "But in my agency I worked 60 hours a week, I can certainly see 40 to 50 clients a week in private practice." It's just not really possible. So, it really has to then become much more strategic in fee setting instead of saying more is less, we have to start thinking less is more in terms of number of caseload clients and number of hours per week because there are so many roles happening behind the scenes that we just don't take account for.

TIFFANY McLAIN: That's a really good point and it makes me think about the MAKE BANK aspect of my business name. So, first of all, I run Facebook ads and we get all kinds of controversial comments in our Facebook ads with a name like the Lean In. MAKE BANK that is directed towards therapists and-

PATRICK CASALE: [CROSSTALK 00:24:37].

TIFFANY McLAIN: Say it again.

PATRICK CASALE: [INDISCERNIBLE 00:24:37] what are some of your favorite [INDISCERNIBLE 00:24:40]-

TIFFANY McLAIN: Oh, my God.

PATRICK CASALE: …that come up?

TIFFANY McLAIN: Something I've been getting recently which is funny with some new ads is they're making comments about my appearance, "Oh, look at this therapist's dress, this is not how therapists dress, and look at her hair. I don't like this so much." And can we have a conversation about race books which we don't go into? I'm actually very gracious in my comments, but all kinds of things like, "This is disgusting, people need help, and you're out of here encouraging people to make more money." You know, blah, blah, blah. 

But there are also a lot of therapist's comments who are, "I want more of this. Hey, because of this I was able to do X, Y, Z." But the Lean In part, I think, you know, that's harder to make sense of than the MAKE BANK part. 

But to your point, if a clinician is seeing 40 or 50 people a week, I'm going to say something maybe controversial, it's not controversial to me, but maybe for people listening. I assert that that therapist is not giving quality care. I believe it is impossible, I will say it factually, it is impossible to do quality clinical work if you're seeing, I'll even say 30 people, 30 different people a week, and you can't set boundaries on your time, and you're barely able to pay your own bills, but you're not even looking at your own financial situation because you're too scared. All of that is absolutely showing up in the clinical work. It's absolutely informing your ability to serve your client and I'll say, making it so you cannot.

You are likely what you touched on earlier, Patrick, in a codependent relationship with your client, where you're struggling and they're struggling, and there's only so much you can do, and hopefully, that client will leave you and they're going to make up some excuse, like, "Oh, you know, I feel so much better." Or "You know, this time just doesn't work." Or, "This is too expensive." They're going to say that and good for them because they need to get out of this codependent relationship and that's a sign of hell. 

If a therapist isn't able to have breaks between their clients, where they're getting food, and taking walks, and taking notes, if you don't even know the name of the person who's coming into your office next, much less have had time to really think about their case or their situation, you're not getting your own weekly clinical consultation, you're not going to your own therapist to continue to understand the way you're interacting with your clients, you're not doing good work. And you can't do all of those things, not to mention, healthy eating, going to the gym, taking vacations.

PATRICK CASALE: Bathroom, peeing. 

TIFFANY McLAIN: [INDISCERNIBLE 00:27:02] you can't be helping your clients. And so, I would assert that it's unethical, actually, to be seeing 40 people and burned down, and overwhelmed, and using the story that I'm being accessible are really helping people as a way to maintain a codependent dysfunctional therapy practice and therapy relationships. 

PATRICK CASALE: Damn, yeah. I agree 100%. I agree 100%. And, you know, this isn't to shame anyone who's listening who might find themselves in that situation. But I want you to really reassess the situation that you're in because your mind, your brain, your executive functioning, your nervous system, everything that goes into being an attuned empathetic helper gets impacted by the work that you do. Every single session you're absorbing, and listening, and holding space, and remembering details, and it really starts to get murky, it really starts to get challenging once you push yourself past that capacity for whatever reason you're giving yourself for doing so. 

And it's a lot. It sounds counterintuitive, but if you are able to really embrace the lean inside, and up your fees, and understand the private pay side of things, you are going to be able to help your community in such a amplified, and more magnified type of way where you are going to have much more of a ripple effect and seeing client after client after client because then you can start thinking about, can I donate resources, and time, and money to causes that I care about? Can you support people that are unable to be supported with the resources that you've created for yourself? 

And that has such a big impact instead of saying, like, I'm going to see a client three times and then they're never going to call me again because like Tiffany said, you're just not at your best. And that doesn't mean we can't be at our best as humans, but when you're past your capacity, when you're past your threshold, it shows, it shows up in the therapy room.

TIFFANY McLAIN: I think that, you said this earlier, Patrick, you spoke to the ways that many of us become therapists as a way to work through, or unwittingly, or unconsciously when we start out to work through our own traumas, attachment traumas. And if we're not aware of how that's currently showing up in our practice, we're going to continue to replay them and play them out with our clients. 

And I think that's one of the reasons why the money work is so hard. I pretend that our program is about making more money but it's actually a clinical program. I don't know if people would buy it if I said, "[INDISCERNIBLE 00:29:50]." Although I don't have therapists [INDISCERNIBLE 00:29:53] say you're going to make more money either to be frank. 

And if you're seeing 30 people a week or even if you're seeing just 15, but you're struggling because you're charging $80 or, you know, getting $60 on a copay, whatever the situation is, the reason you're keeping yourself in that kind of environment, financially broke, I can't look at my finances, is because there's likely something unconscious going on that you haven't yet been able to look at in your own life, in your own personal dynamics. 

And it's scary, I'm glad you encourage people, you know, we're not doing this to shame you. This is deep, scary, difficult work. And so often, we create practices, our private practices, our businesses to avoid doing some of the deeper work. 

When therapists suddenly are seeing 12 clients a week and making $150,000 that creates a whole lot of space, and time, and resources with nothing to do but look over here at the psychological or unconscious patterns, scary things, our own childhoods that we've been avoiding. 

So, I can see why a therapist would not want to do that work, and everyone listening, you enter this work because you truly want to help people and you cannot truly help people if you're not helping yourself, and you cannot help yourself if you're broke, and burnt out, and seeing 40 clients a week, not to mention, all the other things that go into running your business.

PATRICK CASALE: I agree. I really agree wholeheartedly. And you know, I love the goodwill and this bleeding-heart martyr syndrome that helpers have of like the best of intentions, but you can't pay the bills with that. And you can't take care of your own mental health, and your own physical health with that mentality. And it does carry over. And as you develop longevity in this career, it takes a toll. And that's why we see such an increase in substances with helpers, that's why we see such an increase in mental health with helpers, suicidality. I mean, there's so much, that's why we see a lot of helpers leaving the helping profession. 

So, there are lots of things to examine here. And it's not as simple as just saying, well, I believe this, or I believe this, there's a lot of psychological components behind the scenes that are happening. And I'm really glad you mentioned that because there are a lot of blind spots that need to be worked through throughout the career. And that's why ongoing training, and learning, and supervision, and mentorship are so crucial. 

But I think, you know, one thing that was popping up into my head, ADHD, like, rabbit hole right now is like, what about what do you say to folks who are like, "I can't pay my own therapist X amount. So, how can I charge X amount?"

TIFFANY McLAIN: [INDISCERNIBLE 00:32:36].

PATRICK CASALE: [INDISCERNIBLE 00:32:37].

TIFFANY McLAIN: [INDISCERNIBLE 00:32:38] beating my head against this desk, the glorious thing about… if we're talking about therapists in private practice, the glorious thing is we have no limit on our income. So, if we want to pay our therapists for the good work they're doing, their 200 or $250 per session, we can raise our [PH 00:33:00] beans. It makes me crazy when therapists talk about, "Oh, I can never pay a therapist that much." Because they're subsidizing, basically. 

I had a supervisor who said this once, when people asked the supervisor for a sliding scale, he said, I don't know if he actually said this to his clients. But here's how I thought about it, why would I subsidize your fee? Why would I take my professional work and actually pay out of my own pocket? Because that's what you're really doing. If you need $150 per session, to be able to pay your bills, and live, and take care of your kids, and you're charging 80, I'm going to go do the math on the slide. You're literally giving that client $80 every week right out of your own pocket into their pocket. Why? Maybe there's a good reason to do it. But I don't want to know what that good reason is. 

So, if we're going to go to our own therapist who may be charges 250, and for whatever reason, we're paying them 150, I would encourage every therapist ask why are you asking your therapist to pay you $100 a week, up to $400 a month to subsidize your therapy? I suspect there are some attachment stories there, some dependency needs there, or stories there that are going unaddressed. 

The moment a therapist starts thinking in this way and realizes they're subsidizing their client's treatment, while they're asking other people to subsidize their treatment, there are a lot of really interesting conversations to be had there and a really interesting unconscious work, they can start becoming conscious. 

PATRICK CASALE: Yeah, absolutely. That's a really great way to put that and reframe in perspective. If you're seeing 15 clients a week, you know, upping the fee by $10 per client has just paid for your therapy session too. It's as simple as that. And we don't think about it as simplistically because, again, we shy away from the numbers conversations, and the struggles about fee increases, and rate increases, and no-show policies, and cancellations, and all the things I could go into, that I don't want to go into right now. But there are a lot of things that come up when we start talking about money. 

And there are so many ways to offset, if you're thinking like, well, Tiffany and I are just really moving and buying into capitalism, we live in a capitalist society. That doesn't mean I agree with the capitalist values. But we do live in a society that values money, money being made. We also live in a society where we have to pay our bills and our staff. And I think that if you can get behind the mentality of understanding the money, and the flow, and energy of money in your business, you can offer things that you want to offer. Like, if I charge full fees for my sessions, I can build in a pro bono slot into my caseload if I want to. Because, again, I've done so strategically, but I'm not doing that every time someone calls me, and then I feel bad because I'm talking about money. It's that I intentionally have X amount of slots or X amount of caseloads. 

And it's got to be intentional, it's got to be strategic, it can't just be like, whatever emotional like heartstring is played today. That's where I'm going with this. So, because then you will look at your caseload and be like, okay, this person pays 30, this person pays 70, this person has insurance, this person does this, and you have no fucking idea what you are going to make that month and there is no way to budget for your bills or your livelihood, if that's the way you're operating.

TIFFANY McLAIN: That's exactly right. So, we therapists, I count myself in this group, are so educated and intelligent in so many ways. And we're very astute, not astute, we're very good at throwing around big words that shut down the conversation like capitalism [INDISCERNIBLE 00:36:42]. It takes courage to actually encourage that conversation to continue going. When you say capitalism, what do you mean? How does that impact your clients? What does that mean? Like, really going deeper, ethics? Ah, everybody shuts up? 

What's another one that used to come up all the time? Insurance, when people would talk about what rate they're getting in insurance? Hey, that's… what is it? 

PATRICK CASALE: Insurance fraud, it's [CROSSTALK 00:37:12].

TIFFANY McLAIN: No, it's not insurance fraud, there's another word, like, when people get out, I don't know the word is, but problem therapists used to throw out. We can't say what our rates are because that's insurance something and there's so many things where we get terrified, again, because of our histories, where there were real things to be scared of but we really had to shut up. We no longer have to shut up even if it feels that way. 

So, really, I encourage therapists, if things like capitalism, or ethics, or I'm a black woman in San Francisco, that was when I actually struggled for a minute with charging, who's going to pay me that? When those beliefs come up and feel so heavy, and so real, and so unexamined, I do encourage you to go to a place with people who have similar values to you but are doing what you want to do. Find therapists, if you're a black woman, find a therapist who's a black woman, who's charging, you know, 250 per session, doing really good work, who you really respect, or find someone in the queer community who's doing really good work, who you really respect, but they're charging and having a practice set up like you want. 

And ask them how does capitalism play into this? How do you think about this in terms of giving back? I really encourage you to go out and find people to have these deep conversations with, not just like you said earlier, Patrick, an echo chamber, where we throw out big words and shut everything down, and then, get out of that conversation.

PATRICK CASALE: I think that's great advice. And I think it's important to also seek those folks out, and pay them for their services, and pay them for their time because that's also how you can move into the mindset of like, I'm paying someone because I value their time. 

I tell this story a lot. But you know, my wife has federal BlueCross, BlueShield, I'm very fortunate, I'm very grateful, we have great health insurance. And I have a private pay therapist who's 250 an hour, but I chose her specifically because she's IFS level 3 trained, only specializes in working with neurodivergent entrepreneurs who feel like they're not good enough. 

Okay, sign me the fuck up because like [CROSSTALK 00:39:101] what I need right now in my life. And there have definitely been times where I also needed to use my $10 copay in life. 

And like, I'm not judging any of you who are listening for whether you set yourself up as pay what you can, your insurance, your hybrid, your private pay only. But the thing that I can't stand is when we start throwing our opinions into how other people are running their businesses, when someone's like, "I want to make X amount of money this year." And then all of a sudden there's 100 comments about why you shouldn't do that. Who the fuck cares? Like, it's your own business. That's why it's small business ownership and that just is a big pet peeve of mine that happens quite a bit. And I think if we can move more into this mentality of understanding where these narratives come from, it will be a lot easier for you to navigate your day-to-day and your entrepreneurial journey.

TIFFANY McLAIN: I'm going to be doing a workshop coming up. It's one I ran last year, too. And the first training of the series is something about the ethics of setting fees. And we go step by step through what the ethical guidelines actually say about fee setting. And the crazy twist, hopefully, I'm not going to give it away, is that the ethics have a lot more to say about how we treat each other as colleagues than it does to say about how we set our fees. And so, really what I coming in talking about ethics when a coworker says, "Hey, I really want to charge X." Whether that X is, well, I'm going to disagree because I've been saying a whole bunch about how if you're seeing 40 people a week, I have judgments about how that's impacting your business. So, I'm not going to be come in here and say I'll give my opinion about how our businesses ought to be run if they're going to be sustainable and take care of you. 

But I'm in here, and I think Patrick is too. We're here advocating for you, as a therapist, who if you spend all your time advocating for your clients, we're coming in and advocating for you and your well-being, so you can get mad at us for that if you want to, I think we welcome it, that's part of your journey.

PATRICK CASALE: Yeah, absolutely. Couldn't say it better myself. And again, it's just one of those conversations in the helping world that is always going to be a buzzword, there's always going to be a motion behind it, and it's just as so complex, and there are so many layers when we start talking about money. And if it's making you feel any sort of way, I encourage you all to do some journaling, do some reflecting, take a step back, take some breaths, and just get a good understanding of like, what is coming up for you when you start talking about the money and the money coming into your business. And talking about how to work through some of the narratives that have been created, culturally, professionally, ancestrally intergenerationally. There are lots of resources out there, there are lots of free resources out there, there's so much support right now, podcasts, Facebook groups, coaching programs, freebies that people offer, like so many ways to start examining your relationships with the things that can keep you afloat and make sure that you have sustained success and longevity in a career where that is often not the case.

TIFFANY McLAIN: Beautiful. I agree. And I love what you said about finding someone and consulting with them. That's one of the things we encourage, one of the exercises we actually do in our program is if we want to charge to 225s and we're terrified of it, I say go find a therapist who's charging that, set up an hour of their time and learn from them, see what it feels like to sit across from someone who's charging what you want to charge. I think that's excellent feedback for anybody listening to this episode. 

PATRICK CASALE: Thank you. This has been fun. And I think this is a great conversation, and hopefully, a conversation starter for a lot of you listening. And Tiffany has a ton of wisdom, and support, and guidance, and has so many resources around this topic. So, I just encourage you to continue to be uncomfortable with this and examine the why behind it. And really work on those blind spots as you go as a business owner. It'll serve you long-term. 

So, Tiffany, thank you so much for making the time, and coming on here, and just talking about a topic that is unbelievably important, but also unbelievably controversial.

TIFFANY McLAIN: It's my pleasure. Thank you for having me. And thank you for being persistent. I put you up for long, Patrick, I'm like, "I'm so busy, Patrick." But I've had a really good time and I am honored that you actually continued to ask me to be on the show.

PATRICK CASALE: Persistence is key, all the people [CROSSTALK 00:43:36].

TIFFANY McLAIN: Persistence, it is.

PATRICK CASALE: …in group chats can tell you it's definitely a strong suit, maybe to their annoyance. 

TIFFANY McLAIN: I love it. 

PATRICK CASALE: Tiffany tell the audience where they can find more of what you're offering, more about Lean, and just more about what you have coming up.

TIFFANY McLAIN: Sure, folks can go to my website leaninmakebank.com/workshop. And there I have a 90-minute workshop where I go through all of these ideas beginning to end, and also, I tell you how you can work with me if you go there and listen.

PATRICK CASALE: Sweet, that stuff will all be in the show notes so you have easy access to Lean, and Tiffany, and all of her information. Just want to say thanks again for coming on and making the time. 

To everyone listening to the All Things Private Practice Podcast, new episodes are out every single Sunday on all major platforms. Like, download, subscribe, and share. Doubt yourself, do it anyway. See you next week. Thanks.