In October of 2012, Counseling Today published a column I wrote on the topic of avoiding the “nightmare employee.”

My clinical team read the article, and quipped, “Oh sure, bash on the employees! What about the counseling practices?”

“Fair enough!” I said, and agreed to write an article from the clinician’s perspective.

While it’s true that a poor hire can wreak havoc on a practice, it’s also true that a practice’s clinical staff is the lifeblood of the company. Over the years, I have seen practices suffer, and fail outright, because they were unable to retain their clinicians. This month, per the request of my team, I present to you 9 reasons why great clinicians jump ship:

1. They are Underpaid

Wages are low in the mental health field, especially for masters-level providers, who insurance companies pay around 15% less than their psychologist (Ph.D.) counterparts, for the exact same service! Hence, many practices struggle to pay their counselors a wage in balance with their role.

But sometimes just as important as paying a generous wage is communicating to staff the competitiveness of their earnings. For instance, if a practice is paying their counselors as employees, a competing practice might offer what looks like more money. However, the competing practice is paying their staff as independent contractors, which means a whopping additional 7.65% tax difference for the clinician. Similarly, I know one practice that pays their staff what seems like a low percentage of client fees. Yet, many of their clients are full-fee cash-paying clients. Hence, even with the “low” split, the staff earns more than their counterparts in the community.[i]

Wages are often the reason for clinician exodus. When it comes to staff compensation, the key is both good wages and good communication about wages.

2. Medical Billing Problems

Clinicians will leave a practice fast if they are not being paid for their sessions. When it comes to medical billing, a lot can go wrong: sessions can go unpaid without pre-authorizations, claims can be misfiled, and poor follow-up / claims tracking can hurt cash flow.

However, simply getting paid for sessions isn’t enough. Clients regularly have questions about co-pays, deductibles, and their insurance benefits in general, and if a practice’s medical billing team isn’t available to answer those questions, it’s the clinicians who will suffer the complaints of stressed clients who can’t get their questions answered. As one clinician explained, “My client called our biller 5 times, and she never returned his call. This service reflects poorly on me!”

3. Inadequate Administrative Support

Counselors want to be counselors. They don’t want their days bogged down by administrative duties: answering phones, scheduling new clients, printing forms, faxing, ordering supplies, vacuuming, dusting, restocking toilet paper, etc. Counselors can be expected to do some of these things, and even chip in from time to time, but administrative staff should be primarily responsible for administrative tasks. 

Many practices struggle here, because administrative support is costly, and requires managerial oversight. I have known practice owners who have tried to solve their “admin support shortage” by compensating their clinical staff to complete admin duties. This doesn’t work! Either (A) the compensation is too low and the counselors would rather be in session, or (B) the owner is paying a professional wage for receptionist and janitorial tasks, which makes the business unprofitable.

4. Frustrating Systems

Every company needs systems. Without them, there is chaos. However, systems can get out of hand. For instance, I was recently visiting a practice where, after each appointment, the counselors needed to complete Form A, photocopy it, staple one copy to Form B, file A&B in Cabinet D, then add the other Form A to a “Daily Reports Stack,” until the end of the day when they print a “Master Log” on which they tally all the data from…getting the picture?

Paper-based systems don’t have the market cornered on inefficiency. Electronic systems can be just as bad, or worse! A while back, one of my counselors was so frustrated with our EHR program, he exclaimed, “I’m sorry, but I’m not taking any more clients if I have to use this EHR system. I hate it that much.” I felt his pain, and we now have a new system.

5. Poor Office Maintenance

A counseling office should be plug-and-play for counselors, and extremely well kept. If clinicians don’t feel proud in the space they’re working, they’ll join another practice, or open their own office. Still, I have seen practices run out of light bulbs and toilet paper, let a layer of dust collect on the bookshelves, and use furniture so threadbare and old that the springs in the chairs and couches had broken. How nice should your office be? Take a look at the workspaces offered at, and To compete, your counseling office needs to hold its own against spaces like these.

6. Lack of Appreciation

I was recently in a meeting with a counselor who said, “I have worked at XYZ counseling for 6 years, and I get no appreciation. I’ve never gotten a raise or a bonus, and this year they forgot my birthday.” Showing appreciation isn’t really about money, it’s about gestures. There are many ways to do this. To start, honor employment anniversaries, notice birthdays, and acknowledge jobs well done. Avoid gift cards, unless you are giving over $100. Instead, try a company-wide pronouncement of appreciation, and present a small, thoughtful gift.

Showing appreciation is harder said than done! At my company, I have found it very difficult to keep up with the never-ending current of birthdays and employment anniversaries. Day-to-day operations and “crisis as usual” can easily drown out those important dates. In fact, after 5 years, my company is only now getting its act together in this department.

7. Lack of Promotion

People need to feel that they’re making progress in their careers. However, in most counseling practices, clinicians’ ranks, titles and compensations tend to be flat. How demoralizing! There are many ways to promote your team. If you can’t raise wages, you’ll need to get creative. Offer senior staff better offices, first dibs on new equipment, and improve their title and rank within the company. Have performance reviews with staff no less than once per year, and even more frequently with newer staff. Your team should always know exactly what it takes to make it to the next level at your practice.

8. Culture and Community

Never underestimate the importance of culture and community. I have been considering opening a new office about 10 miles from one of my practices. To gauge staff interest, I asked my team if they’d be interested in seeing clients at the new space. While several of them live closer to the new location, no one has volunteered because they don’t want to miss out on the community we’ve formed at our present location. One counselor wrote, “I have a crush on [new location] so I would fo’ sho’ be interested…[except]…if the office is so small that it would only be me. That would be too lonely for me, and I’d end up needing my own services. ;)”

9. Not Enough Clients

Last, but in no way least, is clients. Of all the things clinicians want and need from a group practice, clients is paramount. Some practice managers still don’t see this. Too many practices fail because they hold to the policy “our counselors need to find their own clients.” It works in some industries, but it’s a bad business model in mental healthcare. It’s good to offer bonuses and promotions to clinicians who generate clients for their caseloads. However, a practice owner should consider finding clients 100% their responsibility.

The Challenge

As a business owner or manager, your job is to create a work environment that is so interesting, stimulating, challenging, encouraging, and just so good that the entire staff wants to come to work, and elects to stay employed with you for life. This is easier said than done!

It’s easy for me to write on the topic of employee retention, and create a ruse that my practice is perfect—it’s not! To that, my team will gladly attest! In fact, at various junctures in my company’s history, we have struggled (and still do struggle) in some way with every issue listed above. Still, the vast majority of my team has stayed employed with the company, I believe, because they know how hard I—and the other managers—try and care. If something in the company is sub par, I won’t sleep well until it’s fixed. And when things are going well, I lose sleep asking the question, “How can I make things even better?”

Are you ready to invest the time, energy, and money necessary to create a company that can recruit and retain excellent clinicians? What have you done that has worked, and what hasn’t? Let’s discuss! Post your comments below!

Counseling Private PracticeDr. is CEO of Thriveworks, is Private Practice Consultant for the American Counseling Association, and Author of “How to Thrive In Counseling Private Practice.” Learn more at

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[i] Some do not approve of paying staff a percentage of session fees. I use the example, as it is still a widely utilized method of compensation.