Private Practice
When Assumptions Cost Us: How Misreading Client Priorities Impacts Private Practice Growth
George Nelson
At a recent Australian Counselling Association (ACA) symposium, I presented a compelling comparison between how therapists believe clients experience therapy and what clients actually report, based on my work at Acua Counselling and Therapy. Five simple questions were posed to 300 therapists — answered from the imagined voice of their clients — and then compared to over 1500 responses from Acua clients between 2023-2025.
Across all five questions, the pattern was consistent and concerning: practitioners significantly overestimated how positively clients perceive their therapeutic experience. The gaps revealed by the comparison point to risks not only for clinical outcomes, but for the commercial sustainability of private practices.
This article summarises the five core areas of discrepancy and explores their implications for enterprise growth.
1. “I love my therapist because…”
Symposium participants assumed that clients valued characteristics such as Unconditional Positive Regard, knowledge, caring, empathy, compassion, warmth and kindness. These are indeed foundational qualities of the therapeutic relationship; however, they are also qualities that most therapists believe they possess.
Our sample of client responses revealed that what clients value most is quite different (Acua, 2025). Clients highlighted safety, consistency, and accessibility (including convenience of location and availability). These characteristics relate less to the therapist’s internal qualities and more to the client’s lived experience of the therapy environment.
This misalignment has several impacts on business growth. When therapists market themselves primarily through adjectives like “warm” and “empathetic,” they become indistinguishable from thousands of others. Conversely, when marketing emphasises reliability, predictable support, and accessible practice structures, clients feel reassured before therapy even begins.
Misreading client priorities can also reduce retention. A client may find a therapist kind yet leave early if they perceive inconsistency or a lack of structured reliability. Likewise, consider service design — everything from scheduling systems to waitlist management — clearly communicate your benefits rather than your operational or therapeutic approach.
Understanding these preferences allows practitioners to shape their practice in ways that increase engagement and foster stronger word-of-mouth referrals.
2. “I see my therapist…” (Weekly, fortnightly, monthly, or as needed)
Therapists at the symposium estimated their client-base as follows: 9 per cent monthly, 59 per cent fortnightly, 20 per cent weekly, and 11 per cent attending as needed or having completed therapy.
Our data sample, however, frames attendance through a behavioural-engagement model:
- Malaise (monthly)
- Active (fortnightly)
- Enthusiastic (weekly)
- Desired (as needed)
Each of these patterns carries unique implications for private practice sustainability. The Malaise group — the monthly attenders — typically represents clients struggling with motivation or commitment. Without targeted strategies such as reminders, strengthened routines, or clearer treatment plans, these clients are the most likely to disengage. Improving the retention of this group can significantly increase practice income, even if the absolute number of sessions per client remains low.
The Active group, which aligns with the 59 per cent of fortnightly attendees reported by therapists, forms the financial and clinical backbone of most private practices. These clients benefit from regular engagement and tend to achieve the best therapeutic outcomes. They also create predictable income streams that support enterprise stability.
Weekly or Enthusiastic clients may appear ideal from an income perspective, but they present potential risks. While some clinical contexts justify weekly therapy, others may reflect dependency, urgency, or instability. Without careful monitoring, weekly attendance can create unsustainable relational dynamics, which may collapse abruptly once intensity subsides.
The Desired group — those who attend as needed — often consists of graduates of therapy who return for maintenance. These clients contribute to long-term practice reputation and referral networks, even if their attendance is intermittent.
Optimising these engagement types requires transparent communication, structured treatment planning, and clear expectations. Practices that proactively support client participation, rather than reactively responding to attendance behaviour, achieve stronger growth and improved client outcomes.
3. “My therapy is goal-driven.”
Only 23 per cent of sample therapists believed their clients saw therapy as goal-driven; 78 per cent felt that therapy “flows naturally.” Yet many clients — particularly in funded services such as NDIS, Medicare or insurance schemes — expect or require clear goals.
Only 23 per cent of sample therapists believed their clients saw therapy as goal-driven; 78 per cent felt that therapy “flows naturally.” Yet many clients — particularly in funded services such as NDIS, Medicare or insurance schemes — expect or require clear goals.
Goal-driven therapy supports measurable progress and strengthens retention by giving clients visibility of their journey. Flexible, relational approaches are equally important, providing the responsiveness required for trauma-informed or exploratory work. The risk arises when therapists rely on flexibility alone. Without articulated goals, clients may interpret sessions as directionless, which reduces their motivation to continue and diminishes the perceived value of therapy.
A hybrid approach—goal-oriented but adaptable—is widely considered best practice and is also the most aligned with client expectations.
4. “My therapist lets me lead and listens to me.”
Therapists expressed near-total confidence in this domain, with 99 per cent believing their clients feel empowered. Our data contradicts this sharply: 67 per cent of clients feel empowered, 25 per cent feel dependent, and 8 per cent are unsure of their role in therapy.
Client dependency is both a clinical and commercial risk. Dependent clients often struggle to apply therapeutic strategies independently, are more prone to early dropout, and may perceive therapy as something “done to them” rather than a collaborative process. This perception weakens outcomes and undermines long-term engagement.
Practitioners who assume all clients are empowered may unintentionally overlook opportunities for psychoeducation, shared decision-making, or strengthening the therapeutic alliance.
5. “My therapist uses interventions that help me grow.”
This question exposed the deepest gap. Therapists overwhelmingly believed (99 per cent) that clients recognise the interventions being used in therapy. Yet only 23 per cent of clients agreed. 9 per cent felt no meaningful interventions occurred, and a substantial 68 per cent were unsure whether interventions were used at all.
This suggests that many clients cannot identify what therapeutic techniques are being applied, or how these relate to their progress. When interventions remain unnamed or under-explained, clients may perceive therapy as unstructured conversation rather than a purposeful process. This perception directly reduces retention and referral potential.
Practices that clearly explain interventions, link them to goals, and reinforce application between sessions dramatically increase client engagement, perceived value, and word-of-mouth growth.
The ACA symposium findings highlight a consistent pattern: therapists often misunderstand what clients value, what they need, and how they experience therapy. These misalignments are not minor—they influence retention, outcomes, marketing success, and the long-term sustainability of private practices.
Realigning practice with client expectations requires transparent communication, structured support, reliable processes, and a commitment to understanding the client’s lived experience. When therapists bridge the perception gap, they strengthen both their clinical practice and their business growth.
About the Author
George Nelson
George Nelson brings enterprise coaching expertise with a deep understanding of the realities of private practice. His facilitation style is practical, challenging, and supportive, focused on helping practitioners turn insight into action.
George is a qualified registered psychotherapist, clinical counsellor, relationship therapist, and enterprise coach with extensive experience across public sector leadership, education, and private practice. He has worked with children, adolescents, adults, couples, and families, with recognised specialisations in relationship and family therapy, men’s health, and professional coaching. George also brings a unique background in speech and voice production, having supported professionals including presenters, actors, and media practitioners.
Alongside his clinical work, George coaches individuals and organisations to strengthen leadership, wellbeing, communication, and work–life balance. His approach integrates solution-focused, competency-based, and cognitive mindfulness strategies to support practical, sustainable change. George is a strong business development professional with a demonstrated leadership history focused on growth through innovation and agility. He has skills across governance, innovation, strategy, digital transformation, negotiation, government, strategic design and design thinking.