Fixing the Problem of Counselor Turnover in Private Practice

At my practices, in the last year, two counselors submitted letters of resignation because they were tired of the daily commute and wanted to work closer to home, two others decided to work less and cut their hours by more than half, and another two resigned after deciding to migrate from the east coast to California (one had plans to join a commune and take up organic gardening). Even with over 50 clinicians on staff, losing even one counselor is difficult. But it’s all too common.

Monitor the roster of a typical counseling practice and you’ll see a pattern. Every year the lineup of therapists changes by about a third. When I talk with managers, there’s a consensus that one of the most difficult parts of building a counseling practice that provides consistent quality care to clients is keeping their staff.

There’s a well known cultural trend that persons tend to “job hop” more now than in decades past. However—and I’m going to be brutally honest—when looking at turnover within medical professions, with the exception of positions like lower-end techs and CNAs, I don’t see turnover in other licensed healthcare specialties like I do in counseling. My friends and colleagues who are opticians, chiropractors, or PCPs, when they hire a new doctor, that doc is on the team for 5-plus years, and a fair number stay on indefinitely.

There are a number of reasons counseling practices lose good counselors. Assuming you have a practice with plenty of client referrals, a positive culture, good pay, a great working environment, admin support, and lots of respect, here are three 3 tips I’ve found important for reducing provider turnover.

Create a Term Contract

When you bring on a new provider you invest resources into recruiting, credentialing, promoting, onboarding, and training. After this, you pay the clinician the lion’s share of the revenue that comes into the practice. This is all well and good—it’s the cost of having a practice staffed with excellent providers. The problem is, if that provider leaves 12 months later you might find that all the time, effort, money, and risk you’ve invested has left you with a net loss. Worse yet, you’re scrambling to recruit and train a replacement to offer clinical care to clients.

Counseling practices, as a rule, get too many “false positives” when they hire. That is, persons are brought on board that a hiring manager believes are going to be good, long-term, team members, but who end up falling short in some way—such as a premature departure.
Today, my practices have a 3-year term contract for new providers. Assuming we meet our obligations under the contract, if a provider leaves in less than three years there’s a financial consequence for the early departure. This has certainly increased our “false negatives,” people who might have been good long-term team members but just couldn’t bring themselves to sign up for a 3-year commitment.
However, we’re okay with that because we’ve reduced our false positives! On more than a few occasions a potential new team member will talk about how he or she plans to be in the community forever. After hearing about our 3-year term, the story changes to something like, “Well, to be honest, my wife/husband is in a 1-year internship and we’re not really sure what we’re doing afterward.” The term contract weeds out persons who are likely to move, cut their hours, or get tired of the daily commute.

Develop Promotion & Growth Opportunities

Once upon a time I would hire clinicians and overpay them. My thinking—if I overpay and provide a great work experience they’ll never want to leave. WRONG. Something really interesting happens when one has a full caseload of clients, is making good money, and his/her job is cushy (as cushy as possible, that is). One starts thinking, “Well, I’ve been successful at this private practice thing, what’s next for me? Should try something else? Maybe I should start teaching? Maybe I should move to California and take up organic farming!”

I should have known better. People need to feel that their making progress to be happy, it’s positive psychology 101. It doesn’t matter how high you climb, once you reach the top you start looking left and right. The climb is important.

Today we have 12 levels of counselor rank ranging from “Assistant Clinician” to “Summa Clinician.” It takes at a minimum of 7 years to reach the top, but typically much longer. Each rung is achieved when the clinician meets certain criteria including goals that are customized to match the provider’s own professional ambitions. A team member always knows what level he/she is at, and what’s required to get to the next. Of course, with each new level comes a financial benefit of some kind.

We’re doing more with this program every year (and the more we do, the more meaningful it becomes). Now, when we introduce a clinician, we say, “This is Dr. Smith, a Senior-Associate Clinician at our Atlanta Office.” The title also goes on the provider’s business cards. Counselors fight it. A counselor will say “I don’t need the title!” Then, we see him smile and quietly set the cards on the edge of his desk.

Hire Well

No contract in the world will make things good if you’ve made a bad hire. Spend time getting to know applicants. Make sure you know how they work, how they interact with clients, how they respond to challenges and conflict. Find out: how dedicated to being a FT outpatient therapist are they? Have they maintained a full caseload in an outpatient practice before? Why did they leave (check references)? Are they likely to be working in the community for the next 5-20 years? Assuming you are a counselor, you’re trained to see the best in people. When hiring, you need to take off your ‘counselor hat’ and put on your ‘cynic hat.’ In what ways might this relationship go south? Where are these providers’ weaknesses? Be extremely selective. It’s okay if you pass on a good therapist because you’re not 100% convinced it will be a good fit. It’s better to have false negatives than false positives.

Trailblazing

Generally speaking, counselors aren’t comfortable with contracts. They aren’t used to titles and rank. And they certainly aren’t used to a rigorous screening process before being offered a position; that’s okay. Follow the advice in this column and you will be trailblazing. It won’t be easy! But in the end you should have a strong, dedicated, longstanding clinical team.