Building a therapy practice across eleven states: a conversation with Lisa Abrotsky, LMFT

Where the practice sits now

New Reflections Counseling is a group practice licensed across eleven states, Colorado, Connecticut, Florida, Illinois, New Jersey, New York, North Carolina, Pennsylvania, Rhode Island, South Carolina and Tennessee, with an office in each and telehealth throughout. There are sixteen of us: marriage and family therapists, licensed professional counselors, clinical social workers, mental health counselors, and two psychiatric nurse practitioners who prescribe. Several of the team are registered interns and associates working toward full licensure under supervision, which isn't incidental to how the practice is built. It's part of it.

The bulk of the work is couples. We see individuals and families as well.

What surprises people who don't work in relational trauma is how ordinary the triggers are. Trauma is part of everyday life now. Turning on the television is enough for it to surface, a news segment, something in the background, nothing aimed at you at all. People expect trauma to need a dramatic cue before it shows up. Most of the time it doesn't, and that changes what you watch for in a session.

For the concept behind the clinical picture, Shrinkopedia's entry on trauma bonding covers why leaving a harmful relationship can feel impossible.

Founding New Reflections Counseling

I was working in an agency that asked me to do things I was not willing to do. I do not need to be more specific than that. I decided I wanted out of that environment, and starting my own practice was how I got out. That is a less romantic origin than people expect, but it is the accurate one. The practice exists because I was not prepared to keep working the way I was being asked to work.

What got built first was insurance, in Florida. Before a second clinician, before a second location, I got credentialed onto panels. That decision shaped everything after it. A practice that takes insurance is a different business from one that does not, and a harder one to start, but it is the reason we can see the people we see.

Then COVID. Working through it, it became obvious that the need was much bigger than one state. That was the point the practice stopped being a Florida practice and started being what it is now.

What took much longer than I expected was getting onto the insurance panels. Every payer has its own process and its own hoops to jump through, and there is no version of it that moves quickly. It is also why I hold the view I do about training: I learned how insurance works the way most clinicians learn it, which is in the middle of it, with a practice to open.

What I would tell a therapist looking at the same jump is short: if you are not passionate about the work, do not do it. The clinical hours are not the hard part. The hard part is everything around them, and only caring about the work itself gets you through the parts that have nothing to do with the work.

Eleven states, and why each one is two projects

Florida came first. That is where the practice started and where I was first licensed, and it is still the largest part of what we do.

New York came next, and COVID is the reason. The need for mental health help through that period was enormous, and it was obvious very quickly that it was not confined to one state. New York was the point where that stopped being an observation and became a decision.

Which was hardest is the wrong shape of question. They were all hard, and for the same two reasons. The first is that the states are not clear about their own requirements. You would expect a licensing board to publish exactly what it wants. Often it does not, and you learn what was actually required after you have already submitted. The second is that insurance does not follow the states. Getting licensed somewhere and getting credentialed with the payers there are two separate processes that do not line up. A license does not carry you onto a panel. So every new state is not one project, it is two, and the second one is slower than the first.

One correction to the question: PSYPACT is the psychologists' compact and does not apply to me. The relevant one for a marriage and family therapist is the Counseling Compact. And my answer on it is straightforward: we are never going to be part of it. It does not work for our model.

Where we decided not to go is California. The laws there are always changing, and that is a poor fit for a practice already carrying eleven separate licensure and credentialing tracks. Every change would be another set of requirements to chase in a state that keeps moving the target. It is the largest market in the country and we are not going into it, deliberately.

EMDR and Gottman, side by side

EMDR is for the trauma. Gottman is for the communication. In plain terms that is the division, and most of the time it holds.

With a couple carrying trauma history, I start with Gottman and move to EMDR after. The order is the decision. If a couple cannot get through a conversation without it escalating, that is the thing in front of you, and trauma processing asks a great deal of a relationship that cannot yet hold a hard conversation. Gottman gives them the structure to talk to each other. Once that is steadier, EMDR can do what it is actually for.

Doing it the other way round is where I see it go wrong. Opening trauma processing first, in a couple with no working way to talk, tends to produce material the relationship has nowhere to put.

What tells me it is time to move is two things together: the trauma has been identified, and the client is willing to address it. Identifying it is not enough on its own. You can see trauma clearly and the client can still not be ready to work on it, and starting EMDR on that basis is starting without them. The willingness is the second half of the signal, and it is the half that gets skipped.

That's clinical experience, not a study finding.

What makes a couples referral actually work

Lisa answered this one as a standalone expert perspective rather than inside the interview, so the full version runs on Shrinkopedia. The short account, in her terms: referrals fail two ways she sees regularly. The first is that the patient is never told why they're being referred, so the first session goes to reconstructing a reason the prescriber already knew. The second is fit, individual work sent out as couples work or the reverse, usually caught at intake but only as damage control. What makes a referral stick is a real working relationship between the prescriber and the therapist rather than a handoff, and it doesn't need a formal process. It needs the referring prescriber to say the reason out loud to the patient and to stay reachable afterward.

Read her full expert perspective, what makes a psychiatric referral for couples actually stick, on Shrinkopedia.

Supervising across four boards

One correction first: I am a Qualified Supervisor in four states, not three. Florida, New York, Connecticut and South Carolina.

What I look for in a supervisee is simple. Someone willing to learn, and open to all types of clients. Not someone who has already decided what kind of clinician they are, or who they want sitting across from them. Those two things, willingness to be taught, and willingness not to narrow too early, tell me more about how someone will do than anything on their transcript.

What I wish new clinicians understood in their first year is that being a therapist is one thing and knowing how to run a business is another. No program teaches the second one. You can be a genuinely good clinician and still be unprepared for almost everything else the work requires of you: billing, credentialing, insurance, the practical machinery of seeing clients at all. It is the same gap I would fix in training generally, and I see it arrive with every new clinician.

What the boards get wrong is that they all require different certifications to supervise. Four states, four separate qualification processes for the same activity. The clinical skill involved in supervising an intern in Florida is not different from the skill involved in New York. The paperwork proving you have it is, every time. It is the same pattern as the insurance panels: fragmentation that adds administrative work without adding anything to the quality of the supervision itself.

What community-based care actually means

Community-based, in our case, means three concrete things rather than a philosophy.

First, we take insurance. Aetna, Cigna, UnitedHealthcare, Blue Cross Blue Shield and TRICARE. A practice that only takes private pay is available to whoever can afford it. Taking panels is a good part of what makes it available to the people who actually live in the area, and TRICARE in particular means military families, who move often and lose continuity of care every time they do.

Second, there is a physical office in each of the eleven states we are licensed in, not one address and a video link. Telehealth is a large part of how we deliver care and I would not run the practice without it. But being present somewhere is different from being reachable from anywhere.

Third, we train clinicians locally. Several of our team are registered interns and associates working toward full licensure under supervision. They train in the markets they serve, and they stay in them. That is how a practice puts down roots rather than just opening a location.

What has not changed in ten years, and what I would change if I could, is that the insurance companies continue to dictate our clinical expertise. What is authorized, for how long, what counts as necessary, those are clinical judgments being made by someone who is not in the room and has not met the client.

That is the tension in this model and I am not going to pretend it away. Taking insurance is what makes the practice reachable for the people it serves. It is also what puts a third party in the middle of clinical decisions. Both of those are true at the same time, and the second one does not get easier as you grow. It scales with you.

The next decade for master's-level therapists

Where it is heading is not complicated: the field is needed more now than ever. That demand is not going down. What has not kept pace is everything around the work: insurance, policy, pay.

Insurance is always the issue. It shapes what a practice can offer, who it can afford to see, and how long a clinician lasts in the work.

A concrete example: we do not take Medicare or Medicaid. The reason is administrative burden. The paperwork and the process cost more than the practice can absorb. It is a decision about capacity, not about the patients. That is what parity policy tends to miss. It treats coverage as the finish line, when for a small practice the deciding factor is what it costs to participate at all. A benefit nobody can afford to accept is not access.

Two things I would change, and neither is complicated. The first is training. Nothing in graduate education prepares a clinician for how insurance actually works. You come out qualified to do the clinical work and unequipped for the system you have to do it inside: credentialing, panels, claims, what gets reimbursed and what does not. Most clinicians learn it late, by getting it wrong, usually while already carrying a full caseload. It should be taught before licensure, not discovered after it.

The second is pay. It should be fair for the service provided and for the education behind it. That is the whole argument. Master's-level clinicians complete a graduate degree, thousands of supervised hours, and licensure exams, and then carry real clinical responsibility every working day. The rate should reflect that. When it does not, the people who leave are not the ones you would want to lose.

The one fix for the psychiatry to therapy handoff

The handoff is usually the end of the conversation rather than the start of one. A patient is referred, they arrive, and the two clinicians responsible for their care never speak again. We are both treating the same person. Neither of us sees the whole picture.

What is broken is that collaboration is treated as optional, something that happens when two clinicians already know each other, rather than something built into the referral.

The smallest change that would fix the most: have the release of information signed at the point of referral, in the prescriber's office, before the patient ever reaches me. Right now the release is an afterthought. It gets raised later, or it is nobody's job, and until it is signed the two of us cannot legally talk about the patient we are both treating. So we don't. Not because anyone decided against collaborating, but because the paperwork that permits it was never done.

It is an administrative default rather than a change to anyone's practice. That is exactly why it would work.

The advice she stopped giving

I used to tell supervisees that the model mattered. Choose your modality, learn it properly, and that is what will make you effective.

I do not say that anymore. What matters is joining with the client and seeing them exactly where they are, not where the model says they should be at this stage, and not where you would like them to be.

What I tell them now is to be prepared for constant change. The work does not hold still. The clients change, what they arrive carrying changes, the context around them changes. A clinician anchored to a model is anchored to something that assumes the room stays the same, and it does not. That is what moved me off the advice I used to give.

I am trained in EMDR and in the Gottman Method and I use both, so this is not an argument against modality. It is an argument about what a modality is for. It is the tool, not the work. A clinician who has joined well with a client will do good work with an imperfect model. A clinician who has not will not be rescued by a perfect one.