Transparent group practice culture with Jonathan Pishner

Dan King: [0:00] Hello, everyone. I am very much looking forward today to chatting with Jonathan Dan King: [0:03] Pischner, the founder of Apex Counseling. Jonathan, welcome to the show. It is good to be with you. Please give folks some of the basics about Apex. Jonathan Pishner: [0:12] Well, thank you so much for having me, Dan. So we are a small group practice located in Morgantown, West Virginia. Up until recently, we did have a satellite office, but we are now back to just strictly Morgantown. And I have myself as lead clinician with three other clinicians under me, and a fourth if we decide to take on another student counselor, which we'll be interviewing for on Friday. Dan King: [0:34] And what was the genesis of you embarking on this group practice journey? Jonathan Pishner: [0:39] Well, I think probably the same as many business owners. I could not find the job I wanted, and so I had to invent it out of thin air. And I had worked many counseling jobs, was probably four or so in the few years pre-licensure. And like many people, I was doing the thing where you see a couple of clients on the side, moonlighting, seeing, do I want to do private practice? And I was very lucky to have a mentor who said, Hey, look, you're going to have to, you're probably going to have to just make a jump and see if this is really for you and let it just be rough for a while. And that same week I lost my job. So I was like, well, okay, I guess, I guess I'm doing this now. So basically I kind of got shoved off a cliff and I started flapping my arms as hard as I could to see if I could fly. And it turns out I was at least okay enough at it. Dan King: [1:29] I don't, it doesn't seem to me like the ground is going to imminently hit you. So I think you're doing well after 10 years. Jonathan Pishner: [1:37] Yeah, 10 years deep, I feel pretty confident that at least I can keep this level of private practice going. Dan King: [1:42] Excellent. What is fun about it for you? Now that you're 10 years in, you have a little bit of perspective. What's fun about it? Jonathan Pishner: [1:48] Well, really, a lot of it is giving counselors a place to really be their best selves. You know, it's funny, whenever I hire somebody on, there's a six-month to a 12-month period where they're suspicious, like it's almost too good to be true. And so you can tell they're waiting for me to drop it on them where it's like, oh, by the way, here's the on-call phone. You're on call for the next six weeks and we'll call you in at 3 a.m. Or some crazy nonsense. And about six months to a year in, they start realizing, no, that's not going to happen. But one of the things we really try hard to do is give a space for people to do great therapy and then largely get out of their way. And I'll share a thing we've got coming up that's such a wonderful example of that. One of my clinicians wants to do a thing where he wants to tell anxiety-related stories using Legos. Jonathan Pishner: [2:41] And I was like, dude, this sounds great. We'll help you figure out the platform. Like we'll absolutely give you all the support you need. I helped him figure out camera stuff and some of the technical aspects. And I feel like that's one of the things you can't find a ton of other places. And that's one of the things that gives me joy to provide. Because in one respect, the more I build up my clinicians, the risk, of course, I run is that they're eventually going to leave and start their own practices once they learn how to do enough stuff. But yet, I mean, And even though that's happened a fair bit, I just love seeing these clinicians who've come from kind of difficult jobs Jonathan Pishner: [3:17] really mold into their best selves when they're given the space to do it. Dan King: [3:22] Well, not only do you not have the fear that a lot of practice owners do that folks will leave, but you were mentioning to me that you've actively trained the competition in a sense. Tell me more about that. Jonathan Pishner: [3:35] Well, so the nice thing about if you accidentally train your competition, because that's not what I set out to do. It's just what happens. I want people that work for me to be the best clinicians they possibly can be. And so if I'm going to create that, then of course I'm creating extremely marketable people. But yet the alternative seems crazy to me because the alternative is to deliberately develop people into less good clinicians just so I get to keep a cut of the profit longer. And like, as soon as you say it out loud like that, like who the hell would ever want to come to that practice? Who's going to deliberately stymie their clinicians just so they can make a little more money. Dan King: [4:14] Yeah. When you say it that way, no one would ever admit to doing it. And yet perhaps subconsciously there is an instinct amongst some practice owners to do that. Jonathan Pishner: [4:22] Yeah. I want to, I want to say it with empathy, like not, not like yelling at people, But yeah, it's very easy to fall into the chasing dollars situation. As soon as you make one or two or three decisions that are like more oriented towards chasing dollars than providing great therapy, man, that habit can just stick really quick. I've gotten to watch several practices here in town do that. And I will say it really doesn't work out long term in a lot of cases. Dan King: [4:50] And what does that look like? What are some examples of something a practice could do if they were to fall into that trap? Jonathan Pishner: [4:56] Well, if they wanted to self-correct, man, the step one would have to be the hardest part, which is admitting that you screwed up and that you screwed up in service of money. Because, God, that would be a hard pill to swallow. Even as I say it out loud, that almost feels like one of my greatest fears if I ever had to admit that to myself. So that would be the first part. The second part is unlearning secrecy. One of the things that is difficult for a lot of practice owners, to my mind, is all of these things we do behind closed doors. And I mean, the way I said it is correct, is sometimes they'll stymie their own clinicians. I mean, you almost have to unlearn just keeping all of those secrets inside, which that by itself would be a really difficult behavioral proposition. So it makes sense to me how people fall into this, but it would then be a hard hole to dig out of and then changing the entire reputation around it. Because then you have a reputation you've built up for five, 10 years and really course correcting that to a more transparent, to a more client and clinician centered thing. There'd be a lot of work to do for sure. Dan King: [6:01] I think often beyond secrecy, behind secrecy, I should say, there's often shame and guilt, right? These are powerful, powerful energies. And if we feel them, secrecy is often a natural response. And something I think Dan King: [6:16] as business owners, I think it's very, very common. Jonathan Pishner: [6:19] Yeah, it really is. And in my head, I make up that maybe one day if I just do it this way, maybe two or three other people will follow along and maybe the next generation of business owners, seven or eight more will follow them. And maybe one day we can get to this place where businesses do just win-win deals for everybody. Dan King: [6:40] Yeah, I think there's, it's interesting, there's the actuality of win-win and there's the perception of win-win. And sometimes it can be hard to distinguish between those two. It's maybe more of a spectrum than a dichotomy, right? But sometimes perhaps, I could imagine a context in which we were talking a little bit before going on air. Imagine if I pay my clinicians well per area, but I happen to have an extremely good payer relationship. And so that pair relationship is such that my margins are very good. And on a percentage basis, I may not be paying clinicians especially well, but in absolute terms, I am. Right. So that perhaps is one of those ambiguous scenarios where we could kind of argue it either way. Is this fair or is this not? Jonathan Pishner: [7:22] Yeah, I agree with that. I, cause if I was going to create that deal, certainly the thing I would make sure to try and do is offer the best deal in the area. Because if I, if I have like a weird relationship where I can collect more money, why wouldn't I offer the best deal in the area? So certainly to my mind, that almost naturally creates a win-win proposition. And yeah, as I think about it, you know, if somebody like just learning one piece of information changes their perception of the deal, I think you're right. I think you could look at it two ways. But in the most absolute terms, at least if you're trying hard to give people a winning deal, it's hard for me to imagine you're screwing up that badly. Dan King: [8:04] Yes. Yes. Going back to this really beautiful phrase you had of enabling clinicians to be the best version of themselves. Tell me more about how you do that. Jonathan Pishner: [8:15] So one of the things that I find is... Jonathan Pishner: [8:18] A lot of places actually have too many rules that micromanage what people do. So I'll actually give a non-clinical portion of it because this actually goes into good clinicians too. Our newest clinician, whenever she came in, we were going over some of the office policies. And one of the things she was surprised to discover is that we don't have a dress code. I said, we do have a dress code policy. It's just not written down. Here's the policy. Don't do something so dumb that I have to write a dress code. That's the policy. And what was so wonderful about that conversation was at her last place of business, she had gotten in trouble for wearing a shirt with the Inside Out characters. And for anyone listening who doesn't know, there's a Disney or Pixar movie called Inside Out, and it's basically like about how emotions work inside of a person. It's like if you were going to wear a cartoon therapist shirt, it is literally the one you would pick. But because somehow it conflicted with something, something, something about the dress code policy, there was this whole big to-do. Jonathan Pishner: [9:17] And I was like, this is madness. You see children, of course you should wear this. And even at that level, clinicians are so micromanaged. But then as soon as you start taking the shackles off and just invite people to make sensible choices and make good clinical choices, suddenly their IQ triples. But when you stiny them, yeah, they just become instruction following engines. And how are you supposed to be a good creative clinician under that environment. Dan King: [9:45] Yeah. I mean, fear is one of the enemies of creativity, right? And so if there's a part of us that is just concerned that, ooh, even if it doesn't feel like a big deal, you know, how I dress, well, it speaks to how I'm showing up in the world. And there's nothing if not like presence, maybe one of the most important things about being a clinician, right? But if there's that little voice in the back of our heads, that little sort of voice of fear, then I think that creative muse that is so important to good therapy is going to be terribly diminished. Jonathan Pishner: [10:16] Yes, absolutely. And especially fear of what does the supervisor think? If you're going to fear something as a therapist, least fear that you're not providing good enough service because that might help you be a little more creative. But yeah, for heaven's sake, you shouldn't fear your supervisor, your policy and procedure manual. Dan King: [10:34] Maybe another angle to explore how you enable clinicians to be their best selves. We were talking earlier about your background in martial arts and fitness. How does that inform this issue? Jonathan Pishner: [10:46] So in a lot of ways, it's taught me some useful things. Number one is how much repetition matters for skill building. So one of the things that we'll do a lot, especially whenever I run a training for either my in-house clinicians or for CEUs is we'll incorporate almost invariably some type of repetition-based activity for the purpose of, especially essentially encoding a behavior. So when I run my ethics training, one of the things we'll do is we'll run through ethics scenarios, but we're doing the ethical decision-making model. And so I'll make them step one, step two, step three, step four. And invariably what everybody tries to do is they try and jump ahead to step five or six where you're already deciding stuff. And we're like, nope, absolutely not. What was step one? And the reason for this, especially if we think of sports or martial arts. Jonathan Pishner: [11:41] Whenever we're encoding a behavior, let's just take dribbling a basketball. I'm not a basketball player, but this is a nice accessible example for everybody. You know, we don't try and teach people how to dunk and shoot fade away three pointers and do a bunch of weird stuff. We're like, bounce the ball once and catch it back in your hand. Bounce the ball three times and catch it back in your hand each time. And we just slowly start behaviorally encoding a skill. And whenever I do trainings and whenever I'm teaching clinicians, basically I start doing that exact same thing and making sure they're doing the repetition. And then once they start getting repetitions, then they can start being creative Jonathan Pishner: [12:18] and do all kinds of cool stuff with it like you would see in a sport. Dan King: [12:22] So that intuitively makes a lot of sense to me. Given that, where does the temptation to skip to step six come from? Jonathan Pishner: [12:28] A few things. Uh, at, at the experience level I have, I actually have to really conscientiously think through what it was like to be a beginner again, because now certain stuff I've known so long that I forgot what it was like to not know it. And so, uh, I'll even catch myself with some of our newest clinicians. I'll notice, I'll tell them to do a thing, but then they have this like blank look in their eyes. Like they have no clue why we would do that. And I'm like, oh, wait, hold on. What have I failed to explain? And I'll have to back up and figure out what am I leaving out that I've just known for so long that I don't remember I know it. But then on the other side, whenever it's the person who's receiving the information, I would think it's just, this is going to sound mean to say the word laziness, but it's not like laziness in the sense of not wanting to do work. It's schools reward a certain type of laziness because as long as you can get the answer down, you don't have to go through a good thought process to get there. So we actually train students from the time they're seven years old, 12 years old, 15 years old. If you can put the right answer on the piece of paper, it doesn't matter how you got there, you still get your A. And so they're just repeating that instead of going through a full thought process, which is in a way part of the retraining. Dan King: [13:39] Play devil's advocate. But doesn't that approach, isn't it method agnostic such that it empowers people to maybe be their own unique selves? Jonathan Pishner: [13:48] Maybe. I would leave space for that as long as it's not interrupting a person's ability to think well. Because in a clinical room, if we end up in a position where we come into something we've never seen before, the ability to think well will allow us to work through how do I deal with this versus if you're just used to rote repetition, that'll work for some stuff. But as soon as you get that new situation, then you're stumped. Dan King: [14:18] Thinking about my limited martial arts background and very, very limited, but I guess you need a foundation to reach greater and greater points of complexity, right? That's a sort of core aspect of martial arts, yes? Jonathan Pishner: [14:32] Yeah, that sounds right. Dan King: [14:33] Right. And that foundation can often, yeah, it is boring. Maybe one of the reasons it's boring and maybe one of the reasons behind the late, the, you know, your use of the term laziness is that there's this temptation to be perceived by all of us as successful, right? We all want the validation. And what we associate with success in a given context probably is complexity. It is something that looks interesting. Jonathan Pishner: [14:57] It's hard to look cool when you're practicing the basics. Dan King: [15:00] Yeah. Yeah. Jonathan Pishner: [15:00] And so I would agree with you absolutely. Like the temptation to... Add complexity for its own sake just because it feels better and tastes better makes a lot of sense and if you can resist that urge at least until you've really mastered the basics that's a much better way to move from like beginning to intermediate level clinician to really Jonathan Pishner: [15:24] being able to take off makes. Dan King: [15:26] Me think a little bit about language learning last weekend i was at a friend's house. And I was hanging out with one of our investors and his wife. And his wife speaks six languages. I'm extremely jealous. But she is originally Brazilian, so she's got great Portuguese. She's lived in many different countries, many English-speaking countries. So English is there, her husband is Spanish-speaking, and they lived in Asia for a while. And she came out of living in Asia speaking perfect Thai and perfect Indonesian. I'm very envious. I am not especially talented when it comes to learning languages, but I've been playing around with it. And I keep noticing, you know, I'll meet someone like that. And then I'll meet people who have been studying Spanish for five years and can barely say hola. And it strikes me, this is an interesting analogy here, because I think a lot of people are embarrassed to look bad when they attempt to speak a foreign language. And that language isn't their own. And there's something about that pressure of speaking that foreign language, especially with a native speaker, right? It's very, very hard, that pressure, people inevitably are going to make very, very basic mistakes. And it looks bad. It looks to that native speaker like you don't know what you're doing. And that's one of the things that our mind in any sort of learning scenario, our mind wants to avoid that. Jonathan Pishner: [16:41] You know, it's so wonderful you brought that up because one of my clinicians made mention of like, oh, hey, what do we do if a client is actually really obviously like way smarter than we are? Like, apparently we have a client in-house that has a dramatically high IQ, like an untrackably high IQ. My clinician was telling me some of the stuff she was doing and she said, when he talks about something I don't understand, I just asked him, hey, can you dumb that down for me? I'm not really sure what you're doing. And I said, well, hold on, we have to pause and talk about this because you're doing something that is so wonderful that you don't even realize, which is you're showing zero shame about the fact that he's talking above your head. And this is a child. I said, that's probably the only adult in his life that is showing no shame at all about the fact that he's just brighter than they are. And one of the things that is so challenging for people, and I was so gratified to hear one of my clinicians doing it, is just not having shame about not knowing. Dan King: [17:42] Yes. And it's so liberating if you're raised in a context and, you know, if you study psychology, you train in psychology or training with smart people. It's very easy to be seen to want to be seen to be smart in a context like that. And so there's something so liberating about trying asking very beginner's mindset type questions. And it can be actually so liberating once you try it on. It's just hard to take that initial step. Jonathan Pishner: [18:06] Yeah. Yeah. Although speaking as somebody who's been working on that for a long time and found how wonderful it is, let me encourage the entire listening audience. If you can shed your shame about not knowing, it is so much more freeing and Jonathan Pishner: [18:21] it feels fine to ask questions and then you'll end up learning more anyway. Dan King: [18:24] As both clinicians in a group practice setting and as owners of group practices, right, where we're trying to enable other clinicians, this is a skill set we can apply very, very powerfully, especially in larger group practices where we may have many clinicians to lead, to manage, quote unquote. It's so easy to think we know exactly what's going on in their lives. If they make a mistake, it's so easy to jump in, right? Right. But this is like, this is curiosity at its core, what you're talking about. Jonathan Pishner: [18:54] Absolutely. And what you're saying is so terrific. Like, yeah, just assuming you know what's up and jumping into it. I can't count the number of times where, and sometimes it's a clinician. Sometimes it's a patient who's like behind on their payments or they're violating some other office policy or like, and, you know, in my instant reaction, wanted to be like, my gosh, I got to go jump all over them. And, you know, hold up, let's just take a breath and let's ask, hey, this is not the way it's supposed to be. And I think you know that what's up and the number of times that has paid off so wonderfully. Dan King: [19:29] Like, yes. Jonathan Pishner: [19:31] And it even happened just this week. I felt that urge to like jump on somebody. OK, hold on. Let me just check. And it turned out that there was a thing happening. And oh, my gosh, I would have like jumped all over somebody who had this horrifying situation. Yeah. Dan King: [19:46] Yeah. Me too. Me too. And there's something beautiful about assuming not just that you don't know anything about the scenario, but that there's almost always something going on in that person's life, right, that you're just not up to speed on. And then there's your own part in this, right? So as a business owner, you bear the burden of ownership, which means when things go wrong, you take it upon yourself to fix those things so often, right? But as business owner, there's a wider variety of things that you can both improve but also fuck up. And so there's inevitably something about your own stuff that is leading to you being very close to screwing something up. And that's such a beautiful area to explore. Jonathan Pishner: [20:29] Yeah, I make no secret of the fact I screw up stuff every week. Um, I, we have a policy going into effect tomorrow and I just finalized it about 10 minutes before coming on this podcast. That should have been done weeks ago. And I had to very kindly apologize to my entire staff who has been freaking out, not knowing what the policy is going to be. And that's exactly right. The more stuff you're responsible for, the more ways and the more creative ways you can find to screw stuff up. And to my mind, that's okay as long as you just do your best to own it and work from there. Jonathan Pishner: [21:07] So many people want to, I don't know, blame and do all this other stuff. It's okay. You screwed up. Just admit. Dan King: [21:14] Is there any... Heuristic you use to distinguish between those situations where we screw something up and it's okay to admit, hey, I made a mistake. But there's going to be other contexts, other kind of performative contexts where an admission like that might actually be penalizing. How do I distinguish between those? Jonathan Pishner: [21:34] Well, I think realistically, it's what is the consequences of admitting out loud that this was the screw up? And first off, if you have managed to screw up in such a way where admitting it out loud can really harm or penalize you. My word, you've really managed to find yourself in a pickle. I'll share one that's now old enough that can't come back and hurt us no more. We did this. We were going to go to being a cash-only practice, and it turns out, due to a very obscure law in our state, the state insurer for state employees, if you are a licensed professional in the state, you are legally obligated to either accept that insurance or turn away literally everyone who has that insurance, which in our area is about 30 or 40% of the market. We had been violating that law for about three weeks. And so I had to like, I had to change everything and I had to come, I don't even remember what in the world we told clients, but it was definitely like a situation where we're like, oh my gosh. So everybody turned out to be cool with it. But yeah, I don't even remember exactly what we did because that was such a panic-fueled situation. Jonathan Pishner: [22:43] But if I was to think through how to do it, what we ended up with and what I would encourage people to do is be as honest as you can be without burning your business down. And that's basically what we did. We're like, hey, we made a mistake. There's a whole thing. And we were just kind of hoping nobody would ask any questions. Thank God nobody did. And it turns out that law is not even really enforced anywhere. But that's what we went with was we were just honest with them to the extent Jonathan Pishner: [23:05] we could without risking burning the place to the ground. Dan King: [23:08] Don't burn your business to the ground. That's some sage advice. Jonathan Pishner: [23:11] Yeah, but be as honest as you can because I think people are very sensitive, especially in this day and age, to dishonesty because we get it from so many places. And even smelling a whiff of it is... You know, it puts people off. Dan King: [23:27] Absolutely. For a good reason. Now that all makes a ton of sense. And I so appreciate your willingness to vulnerably share that example. I think that that's modeling exactly what you're talking about. Jonathan Pishner: [23:38] To me, it feels so neurologically expensive to have to keep up with all of the things I'm allowed to say truthfully and the things I have to lie about and the things I have to dissemble about. And it's like, there's so much energy that I could just spend building a better business and seeing clients more effectively. Dan King: [23:55] I love that term, neurologically expensive. And I almost wonder, it's interesting, I think, so there's sort of the outright dishonesty of, you know, I'm covering something up, some mistake that I made, right? There's that type of scenario. But then there's the type of scenario where it's neurologically expensive to, almost as I'm doing now, say something and then have eight caveats, right? So I think we so often find ourselves in the clinical world in these contexts where we have to be very sensitive, very careful. I'm not saying that that should never be the case, but there is so often a heavy neurological price for that too. Jonathan Pishner: [24:31] Oh my gosh, there is. And actually, you were talking about the sports thing. I actually got this from a lot of my sports and physical therapy. This is where I learned this. And then once I started applying it to therapy, into business owning, I was like, oh my gosh, this is an entirely transformative idea because now, I mean, even when I just, when I just arranged my day, nevermind anything fancy. Dan King: [24:52] Yes. Jonathan Pishner: [24:53] Now I'm like, okay, how much neurological expense am I incurring today? Is this the right amount? So like this, this is actually neurologically energizing. You can get me to show up and say what I know easily, but I have to have nothing Jonathan Pishner: [25:07] expensive after it because as soon as we're done, I'm going to crash. Dan King: [25:10] This has been a super enriching conversation that I thank you for. As we're moving towards the end of our time together, I always love to ask, so when you're not running this great group practice, seeing your own patients, what do you do for fun? Jonathan Pishner: [25:23] Oh, man, I... Very much am in my physical body as much as I can be for my fun times. Kung Fu, Taiji, and Jiu-Jitsu for martial arts. Weightlifting, racketball as much as I can. And then also playing a fair bit of Xbox. I have finally recently gotten back into reading. I lost the habit because of grad school and too much business running. I just started pleasure reading again earlier this year, and that has been so wonderful to get back to. Dan King: [25:54] What are you reading? Jonathan Pishner: [25:56] So I just finished a book and I'm getting ready to see if the library has the next one. There's a fantasy series called The Legend of Drizzt by R.A. Salvatore that I'm late into. And then I'll be retrying Way of Kings by Brandon Sanderson. But that has been a dense read to break into. So that one's been challenging. But there's a lot of wonderful messaging. I've gotten to where I have trouble now spending too much time on any fiction material. Whether it's television movies that doesn't have happy endings just because i deal with so many unhappy endings in therapy like i need that when i my fun time it's always got relatively uplifting messages there's like high levels of friendship high levels of kindness between the main characters you know some surprisingly like good relational dynamics like healthy ones so that one would be the one i would recommend just because it's it's a little fluffy but it's also got good messaging I. Dan King: [26:53] Wonder how much of our mental health crisis is in some way connected to how dark our culture has become. Jonathan Pishner: [27:00] You're absolutely right. Just to tell the story briefly, I watched the first episode of the second season of House of Dragon, and it ended so horrifically. I was like, why am I watching this? This is not fun. What is happening right now? I'm an idiot, and I just stopped watching, and that was the end. Dan King: [27:15] I don't blame you. I don't blame you. Let's end on an uplifting note and let's look for some of those positive, more uplifting stories. Dan King: [27:23] Yours certainly is one, Jonathan. So thank you so much for coming on and sharing these insights and playing with some interesting ideas today. Jonathan Pishner: [27:31] Yes, sir. Thank you for having me. It's been a real pleasure.