Business Coaching for Therapists: Why Your Instincts Stop Working

Business Coaching for Therapists: Why Your Instincts Stop Working

There is a particular kind of quiet in a practice owner's office after everyone else has logged off. You are looking at a number you do not fully understand, or an email from a clinician who needs something you are not sure how to give, or a decision that has been sitting in your inbox for nine days because there is no obviously right answer. And somewhere in that quiet, a sentence arrives. Maybe I am not cut out for this. If you have found yourself looking into business coaching for therapists, I would guess that sentence is why. So let me answer the actual question before anything else: the reason business coaching for therapists exists is that the instincts that built your practice were always going to stop being sufficient at a certain level of growth, and when they do, the friction you feel is a developmental stage rather than a verdict on whether you belong in business at all.

I am not saying that from a comfortable distance. I have been running a group practice for over a decade, at one point with more than sixty people on the team, and I have had that precise thought while staring at financial statements I could not really read. What helped was not more grit. It was two things: finding other practice owners who would say the hard part out loud, which is the whole reason our team built the Therapist Growth Collective, and finding a business educator who could hand me the competencies nobody covered in graduate school.

Here is what I have watched happen to clinician after clinician, including me. Nobody reasons their way off this ceiling alone. You can read this entire article, and then read Courtney's book, and understand the argument completely, and still find yourself on a Tuesday night making the same reactive decision you made last quarter, because recognizing a pattern and interrupting a pattern are two different skills. The practice owners I know who actually got through this did it in the company of other practice owners who were slightly ahead of them. That is what our team built the Collective for, and it is why I keep pointing people there rather than toward another download. What follows is real, and it will give you language for what is happening to you. The part where you change what you actually do on Monday is the part that happens with other people.

The guest on this episode is Courtney De Ronde, CPA. She is the CEO of Forge Financial and Management Consulting, the author of Planning to Scale, and the person behind Scaling Leader, the business education program I have been a client of for going on four years. I want to be transparent about that, the same way I was on the recording. I am not a paid spokesmodel. There is no commercial arrangement between us. I asked her on because her explanation of why practice owners stall is the most useful thing I have heard on the subject, and because most of what gets sold to our profession about growing a practice is either a template or a guru.

Why Do Therapists Struggle With the Business Side of Private Practice?

Therapists struggle with the business side of private practice because we were trained to deliver a clinical service and then handed a small business, with essentially no overlap between the two curricula. Being good at therapy is not a business competency. It is the product.

The scale of this is not small. In the 2015 APA Survey of Psychology Health Service Providers, nearly 45 percent of licensed psychologists reported private practice as their primary work setting (American Psychological Association, 2016), and on the recording I put the figure at 50 percent or more across our profession broadly. Either way, roughly half of us end up owning a small business, and we do it with virtually zero business training, on the assumption that if I am good at being a therapist then I should be able to run a therapy practice.

That assumption is reasonable and it is wrong. It is wrong in a specific way that makes it hard to catch: it does not fail immediately. For the first stretch it works fine, because a new practice mostly needs a good clinician who returns phone calls. The assumption only breaks later, at the exact moment you are least able to tell the difference between a structural problem and a personal one.

If you have not opened your doors yet, the honest starting point is a different question entirely, which is whether you want this at all. We have a whole piece on whether starting a private practice is the right move for you, and it is a better first read than this one.

What I want you to hear, if you are already operating, is that this is the single most common thing our coaches hear from practice owners, and it almost never arrives as a business question. It arrives as a self-worth question. Most people say some version of "I think I am bad at this" long before they can say "I have never been taught capacity planning." Getting from the first sentence to the second one is most of the work, and it is very hard to do by yourself at 10pm.

The Day You Became a Leader Without Noticing

You became a leader the moment you had one other person, and almost nobody notices it happening. An admin. A second clinician. A biller. A fractional marketing person you hired for ten hours a month. Any one of them converts your role from expert serving clients to leader running an organization, and the conversion happens silently.

Courtney describes the disorientation precisely. You are now wearing hats that are, in her phrase, not as deeply worn as the one you have had on for fifteen years. Decisions that used to belong to somebody else are now yours. People are asking you things. And because you are still seeing clients, you never get to fully put down the old hat and pick up the new one. You are splitting your time and your attention between something you are deeply good at and something you have never done, and the natural result is that you start second-guessing everything.

This is well documented outside our field. Herminia Ibarra's research on professional adaptation found that people moving into more senior roles do not simply acquire new skills, they try on provisional selves, experimenting with versions of the professional they might become and evaluating each experiment against internal standards and outside feedback (Ibarra, 1999). In other words, the disorientation is the mechanism, not a malfunction. It feels like incompetence because you are, quite literally, running trials.

We have written before about why practice owners have to lead, not just treat, and the piece that pairs with it on the mindset shift that has to come before the system. Both are worth your time.

What working on this with a coach on our team actually looks like, practically, is not a leadership seminar. It is someone who knows the specific people on your specific team helping you figure out what to say to your office manager on Thursday. The identity question gets answered in a hundred small conversations, not in one insight, and having a person to think out loud with is what keeps you from defaulting back to clinician every time it gets uncomfortable.

Why Do the Instincts That Grew My Practice Stop Working?

Your instincts stop working because they were built for a smaller, simpler version of your practice, and complexity grows faster than intuition does. Courtney's framing on the recording is that early success comes from experience and gut feel, and eventually that expires, because the growth those instincts produced creates a level of problem those same instincts were never calibrated for.

Read that again, because the causality matters. It is not that your instincts were bad. It is that they worked, and the success they produced is what generated the conditions in which they no longer work. You did this to yourself by being good at it. Which is a genuinely strange thing to experience, and it is why the internal narration is usually some version of "I have achieved what I wanted, so why does this feel worse?"

"It's a whole new level that just requires more than our instincts can bear."

That is Courtney's line for this, and it is the one I would put on a wall. Her correction is not more effort. It is adding insight and information that build your instincts up to the new level. That is a fundamentally different prescription from what the therapist-business internet usually offers, which is another tactic.

There is a metaphor in here that has stuck with me for years, borrowed from Donald Miller. The business is an airplane. Sales and marketing are the two engines. The leader sits in the cockpit. Administration and operations are weight. Every one of those is necessary, and none of them is optional, but the more weight accumulates the harder the plane is to get off the ground and the harder it is to keep in the air. Which reframes hiring. Every person you bring on adds lift and adds weight, and if you only ever hire away from the things you dislike, you get a very heavy plane with two small engines. This is also where marketing for therapists stops being a side project and starts being an engine.

One more thing worth saying plainly, since it came up on tape: your business model is a strategic choice, not a default. Taking insurance referrals solves the sales and marketing problem, and that is a real advantage. But it can conflict with the work you actually want to do, because growth and goals work often cannot be billed as medically necessary treatment. The moment you make that shift, you have a marketing problem you did not have before. That is not a reason to avoid the shift. It is a reason to plan it.

Most of the practice owners I work with figured out that their old approach was costing them long before they figured out what to do instead. That gap, between knowing what is not working and knowing what comes next, is exactly where coaching earns its keep. It is very difficult to see your own business clearly from inside it, and our coaches spend most of their time helping people close that particular gap.

How Do I Know If I Actually Want to Grow My Practice?

You find out by asking the question directly, before you plan anything, and by treating "no" as a legitimate answer. This is the part of the conversation I care most about, because I do not hear it offered anywhere else in this category.

There is enormous cultural pressure on our profession right now to build something. Be an entrepreneur. Start the group practice. Add the course, the membership, the second revenue stream. And almost nobody says the obvious counterpart out loud, which is that growth brings new problems that are genuinely hard, and you are allowed to look at them and decide you would rather not. Courtney put it about as clearly as it can be put: you do not have to build a practice that looks like somebody else's practice. If your vision is ten clients a week and a life you like, that is a complete answer. It is not a smaller version of a real answer.

She also names the counterpart risk, which lands harder. The people who never get clear on what they want do not stall out. They drift. They adapt the practice to what early clients wanted, or what a colleague thought they should do, and they end up making every decision reactively. They can still be successful. What they often are not is fulfilled, and Courtney's description of where that lands is a person looking around and thinking, how did I get here, this is not even what I wanted.

If it helps to look at the actual numbers before you decide, our piece on the financial reality nobody warns you about is more candid than most of what is out there. And if what you are feeling is closer to restlessness than ambition, growth does not have to mean growing the business.

If you are reading this section and feeling something complicated, that is worth paying attention to rather than resolving quickly. You do not need to be in crisis, or behind, or failing at anything to talk it through with someone. A first conversation with our team is not an enrollment step. It is a real conversation with a colleague about whether what you are describing is something coaching is actually the right fit for, and sometimes the useful answer is no.

What Business Skills Does a Therapist Actually Need to Run a Practice?

The first one is not a business skill at all. It is self-knowledge, and Courtney puts it before vision, before planning, before anything gets written down. The reasoning is straightforward: if you do not know how you are wired, you will build a business that runs on somebody else's wiring, and then wonder why operating it exhausts you.

She uses three assessments, deliberately, because each measures a different thing. CliftonStrengths, for the cognitive side: how you learn, how you build relationships, whether you are an executor or a relationship builder. The Integrative Nine Enneagram, the IEQ9, for motivation: not what you do, but why you do it. And Kolbe, for conation, which is how you take action when you are striving, specifically how you make decisions and solve problems when you actually care about the outcome.

Taken together, the patterns overlap and the picture sharpens. The goal is not a label. The goal is knowing your genuine gifts and, more importantly, the blind spots that are going to trip you up over and over again. Mine, for the record, is overestimating capacity. I said so on the recording, in front of the person who taught me to measure it, and it was not a comfortable sentence to say out loud.

I know what some of you did when you read the word Enneagram, because I did it too. Pop psych, no thanks. So I want to make the case briefly. Dr. Dan Siegel, professor of psychiatry at UCLA, spent roughly six years developing an integrated theory that layers personality patterns with attachment and trauma to build a fuller clinical picture of a person. We have a whole episode with him on personality and the theory of wholeness, and a companion piece on attachment style therapy and his latest work. In my experience the IEQ9 is the most reliable instrument in that family. You are allowed to be skeptical. I would just rather you be skeptical after looking at the research than before.

Beyond self-knowledge, the competency list is not mysterious: reading financial statements, capacity and resource planning, hiring and role design, communicating a direction to a team, and choosing a business model on purpose. None of that is secret knowledge. All of it is learnable. The reason it feels like secret knowledge is that our profession has no structural place where any of it gets taught, which is a problem with the field, not with you.

Normalizing this is half of what our coaches do in the first few sessions. If you have been quietly assuming that other practice owners learned this somewhere and you missed the day, I can tell you from a decade of these conversations that they did not. Almost everyone is assembling it from scratch, and the ones who assemble it faster are usually the ones who stopped doing it privately.

What Is the Planning Gap, and Why Do Business Plans Never Get Implemented?

The planning gap is the space between what you intend and what actually becomes real, and business plans fail to close it because most planning processes only cover two of the three layers required. Courtney's diagnosis is that the missing layer is implementation planning, and that it is missing almost everywhere.

Her first move is to take the noun away from you. This is less about a plan, she says, and more about a process. We are not trying to build a document or a binder. We are building a rhythm of planning. If you have ever produced a beautiful strategy document that nobody has opened since, you already understand why that distinction matters.

The three layers:

1. Long-term planning. Where do I want to be in three years, where am I starting from, and what are the broad strategies that get me there.
2. Annual planning. How far can I realistically go this year within that three-year direction, and what specific projects do my team, my contractors, and I have to execute to get there.
3. Implementation planning. What we actually change about what we do daily, weekly, monthly, and quarterly to keep the thing moving. This is where capacity, accountability, and communication live.

Most strategic planning processes teach layer one or layer two. Courtney says she has not seen anything that connects all three, and that this is precisely why planning has a bad name among people who have genuinely tried it. They did the retreat. They made the plan. They fell into the gap anyway, and concluded that planning does not work, when what actually happened is that they were handed two thirds of a system.

The psychology research supports this specifically. Peter Gollwitzer's work on implementation intentions found that goal intentions become dramatically more likely to be achieved when paired with concrete if-then plans specifying when, where, and how the behaviour will happen (Gollwitzer, 1999). The intention is not the weak link. The specification is. Which is the same argument Courtney is making from twenty years of watching business owners, arrived at from a completely different direction.

If you want to work the planning muscle at the individual level first, our pieces on goal setting for therapists and planning a career, not just a year are the right on-ramps.

Capacity Planning: How to Pressure-Test a Plan Before You Start

Capacity planning means counting your actual available resources, team, contractors, hours, and dollars, and testing your plan against them before you begin rather than after you stall. Courtney calls it the first implementation move, and she notes that almost nobody does it because almost nobody is guiding people through it.

There are two failure modes and they are opposites. The first is overestimating, which is mine. You can see what is possible and you want it to be real immediately, so you load the year with everything at once. The second is underestimating. You look at a three-year horizon, decide there is plenty of time, and never build enough momentum to get the snowball rolling, so years go by and the practice is essentially unchanged.

Overestimating is not a personal defect, incidentally, it is one of the most reliably replicated findings in psychology. Buehler, Griffin and Ross gave it its name: asked to predict when they would finish their thesis projects, students averaged an estimate of about 34 days and actually took about 55 (Buehler, Griffin, & Ross, 1994). The planning fallacy holds even when people are explicitly asked for a conservative estimate. Your plan is optimistic. Everyone's is. That is the argument for pressure-testing, not for trying harder to be realistic.

So you count what you actually have, and you hold the plan up against it. When they do not match, and they usually will not, Courtney gives you three honest choices rather than one. Scale the year back. Add resources, which usually means money. Or accept that it will take longer. Her analogy is the one you use every day without thinking about it: put a destination into your maps app and it offers you fastest, shortest, and fewest turns. Different routes, same destination, different costs. Fewest turns might take longest, and if you hate merging, that might still be the right route for you.

What you cannot do is skip the arithmetic and move forward blindly, which is the default. And the practical version of this is more concrete than it sounds. If the plan is a new website and a real social presence, the questions are: how many hours a week does that take, what does it cost, what specifically is involved in getting from here to there, and do I have that. Sometimes the answer is yes. The point is that you found out in advance.

This is one of the frameworks that sounds simple on the page and is genuinely difficult in your own business, because you are the one who wants the plan to fit. The version of you reading this article and the version of you three weeks into an ambitious quarter are two different people. That is not a flaw. It is most of the reason our coaches exist, and it is the specific thing a good outside perspective does for you that no worksheet can.

Why Knowing All of This Is Not the Same as Doing It

I want to be straight with you about something before we finish, because I would be doing you a disservice otherwise. Everything above is real. Courtney's three layers work. The capacity test works. People's practices genuinely change because of this material. And reading it is not the work.

Here is what almost always happens instead. You read an article like this one. Something clicks, and you feel a little hopeful, and you make a mental note to run the capacity test before you commit to the next thing. Then the next thing arrives. It arrives on a Wednesday when you have had seven sessions, a clinician has just given notice, and a former client has emailed something you need to think carefully about. And you make the decision the way you have always made it, because you are a competent person operating at the edge of your bandwidth, and a paragraph you read in September has no chance against that.

That is not a motivation problem and you are not broken. You are trying to override an established pattern, alone, at the exact moment the pattern is most active. That is the hardest possible conditions for new behaviour. It is close to impossible to do solo, and I say that as someone who tried to do it solo for years and did not manage it.

What works is different. It is having people who know your specific practice and your specific patterns, who you can message after a hard week, who will help you debrief a decision before you make the next one. For me that has been a business educator plus a room full of other owners. For most therapists I talk to, the room full of other owners comes first, because it is lower stakes, it is where you find out you are not the only one, and it is the thing that makes the rest of it survivable.

If something in this article landed somewhere specific, that is the signal. Come see what the Growth Collective is actually like. No pitch, no commitment, and nobody is going to ask you to have your practice figured out first. That is what the first conversation is for.

You Cannot Do This Alone, and That Is Not a Character Flaw

The second implementation move is communication, and it exists because the plan is not yours to execute by yourself. Courtney's line is that at these levels of growth we cannot do it all on our own, and if we can, we are not thinking big enough.

Practically, everyone connected to the practice needs to hear the same three things: this is where we are going, this is how we are going to get there, and this is what it means for you. That last one is the one people skip, and it is the one that determines whether anybody does anything differently. It applies to contracted people as much as employed ones, which means the fractional marketer and the outsourced biller get the conversation too. Courtney sequences the rollout deliberately: co-founder or business partner first, then the next tier of leaders, then the full team. The order is not ceremonial. Finding out about the direction third-hand is how good people quietly disengage.

I would extend that past your team. The loneliest part of practice ownership is not the workload, it is that there is no one in the building at your level to think with. We have written about therapist isolation and how to build real professional community, and it applies double to owners. And if you are earlier than all of this and still deciding whether to open your doors, start with how to start a private practice instead.

What I kept coming back to after this conversation is that the whole thing reduces to finding trustworthy guides. Not gurus. Not someone selling you a template. People who have been where you are going, who will tell you the full story rather than the highlight reel, and whose advice holds weight when you put it under load. Courtney is one of those people for me, and I will say again that there is no commercial arrangement between us. I just think she is right.

If you want that for your own practice, our team does this work every day with therapists who are exactly where you are: competent clinicians running something that has outgrown the way they built it. Everything we make for therapists lives in one place, and the Collective is the easiest door to walk through first. Either way, stop doing this part by yourself. There is no prize for it, and it is the single thing most likely to make you quit something you are actually good at.

xo,
Dr. Lisa Marie Bobby

Dr. Lisa Marie Bobby is a licensed psychologist, licensed marriage and family therapist, board-certified coach, AAMFT clinical supervisor, and the founder and clinical director of Growing Self Counseling and Coaching. She is the author of Exaholics: Breaking Your Addiction to an Ex Love and the host of both the Love, Happiness and Success podcast and Love, Happiness and Success for Therapists. She has been building and leading a group practice for over a decade.