Dr Andrew Greenland: 0:04

Okay, so welcome to Voices in Health and Wellness, where we speak with passionate leaders transforming care in their communities. Today, we're joined by Brooke Buck, a licensed psychotherapist and ADHD certified clinical services provider and the founder of Cloudbreak Therapy and Cloudbreak Kids, two practices based in Alexandria, Virginia, that provide trauma-informed care across multiple sites. Brooke's clinics are known for their focus on neurodiverse clients and innovative approaches to accessibility in behavioral health. We're going to explore real-world challenges facing small private practices today, from clinic burnout, clinician burnout and access issues to rising expectations from clients and everything in between. So thank you very much, Brooke, for joining us, and you're calling from Alexandria today, I believe. Is that right?

Brooke Buck: 0:51

Yes, alexandria, virginia, and we're right outside of the Washington DC metro area.

Dr Andrew Greenland: 0:56

Wonderful. Could you perhaps start by telling us a little bit about what you've built in terms of Cloud Break Therapy and Cloud Kids and what your current role is within these clinic settings?

Brooke Buck: 1:07

Sure, sure. Actually, next month we're going to be celebrating our 10th birthday for Cloudbreak Therapy. I started in 2015. And it was just me as a solo practitioner. Prior to this, I had been part of a group practice and I decided that I was ready and had the knowledge and training to go out on my own. So I started it and then all of a sudden be known to me.

Brooke Buck: 1:29

It started to grow and more and more clinicians came aboard. We had to then hire administrative assistants to be able to help us manage taking insurance, the billing, all the things behind the scenes. Now we are 14 individuals billing all the things behind the scenes. Now we are 14 individuals and we also. One of those individuals is a psychiatric mental health nurse practitioner. We have on staff to help medication management. Other therapists range from residents, so they are pursuing, they're getting their hours. It's kind of like a postdoc in our kind of mental health world for counseling. It's they're getting their hours to be able to get state licensed. We have some residents and we also have LPCs and also licensed clinical social workers LCSWs as well and they see a variety of different populations, everything from children through adults. We also see families as well as couples.

Dr Andrew Greenland: 2:23

Amazing. And what's your sort of current role in the business, I mean in terms of whether it's of clinical or leadership admin, or a bit of all of the above? How do you spend your time?

Brooke Buck: 2:34

Honestly, a bit of the all above. I rarely work less than 40 hours a week. I do have my client caseload that I refuse to give up because seeing people and making a difference means so much to me. I do administrative things on the side not as much, because I do have assistants and I do supervise. I am also a supervisor in the state of Virginia and other areas as well, and so I do help train the next therapist that we're going to go out into the field and see people as well. So I've trained about eight or nine people to this point over the past 10 years.

Dr Andrew Greenland: 3:11

Amazing. So you're a multi-state provider from. You've got the clinics everywhere. What are the big changes that you're seeing in mental health care today from your perspective?

Brooke Buck: 3:20

Yes, given that we're in the Washington DC metro area, it's kind of hard to just be licensed in one spot because they're so close. So yes, washington DC, maryland and Virginia what we're really seeing we do see clinical burnout and I do experience that with our staff. You know, is it the heaviness of what the individuals coming to us are going through. When you talk about trauma work, it can definitely be a lot, and for that therapist to be in a good mental head space themselves to be able to work with the individual.

Brooke Buck: 3:54

So we are definitely seeing that Boundaries sometimes can be a concern, given the modern technology we have today. People do text, people do send emails after hours and if therapists don't have good set boundaries it can be difficult, leading to quicker burnout. So we really really encourage our therapist and our team to make sure that they are taking care of themselves. They are scheduling time off, they're setting boundaries with when they won't look at any more texts or emails, when they are needing a vacation, some time off and really being able to detach, making sure that they have good things outside of their. They're seeing their clients hobbies, exercise. What are they doing to take care of themselves? So we really try to focus on that. We are seeing an intake and some clinical burnout. We are doing everything we can to address it, to make sure the provider can not only show up for their clients but also show up for themselves.

Dr Andrew Greenland: 4:54

Excellent. I'm guessing this is not unique to your particular practice. I guess this is a niche wide problem.

Brooke Buck: 5:00

Yes, yes, there are. You know there's. Think about the rural areas. There's not a whole lot of providers, so those providers are having a hard time. And then even in the DC metro area you know there's so many practices At the same time it is still a lot of people coming in wanting services, needing services. So trying to find that balance of how many is just the right caseload number and where can I take more clients on, do I offer telehealth for someone in rural Virginia because they can't find an in-person provider? You know we're trying to balance. All that can be quite a bit. So I definitely work with the team to talk about that. We have group supervision. I have individual supervision with everyone that is needing that right now and we talk a lot about that how to make sure we take care of ourselves which is so important, and sometimes it's just the peer-to-peer support can be helpful.

Brooke Buck: 5:50

Like I'm not the only one experiencing this.

Dr Andrew Greenland: 5:53

Of course. I mean, do you think your approach has made an impact on the clinical burnout, certainly in your practices, having this sort of more caring approach and being mindful of the kind of contributory factors that lead to it? Do you think you're making a making a dent in this if it's an industry-wide problem?

Brooke Buck: 6:10

trying our best to make a dent in it every which way we can. The more we can educate ourselves about it, the more we can stop trying to. I tell this to every person that works with me we can't fix anyone. We can give them the tools work. Work with giving them insight, helping them see patterns that they're developing that are healthy or not healthy. We can't fix something. So one thing is really people really struggle with in this field is the imposter syndrome, and that I need to do it. I need to fix it. I need to. Just if I just need one more thing, I could help this person, and that is a big struggle we are also seeing in just trying to reiterate you're here to help and what does helping look like? So many different facets to helping someone. It doesn't mean taking care of it for them.

Dr Andrew Greenland: 6:55

Got it, COVID. I mean it seems like a long time ago and yet it seems like yesterday. But how did that kind of shape the way that you run your services? I guess, like many practices, you had to shift to an online model. I don't know, and I don't know how much of that has kind of carried on since the whole lockdowns disappeared. But how did that whole shift, your practice and the way that you do things?

Brooke Buck: 7:21

It was very interesting how quickly it happened. I had just had my third child just come back from maternity leave and then everything happens and everything starts to shut down. So we easily pivoted, thank goodness, because that's why we have such a great administrative assistant. We actually call her a creative director because she does everything behind the scenes for us. So blessed to have her with us, she was able to get everything kind of easy to go.

Brooke Buck: 7:45

We used to use a system, at first called Doxyme, that was HIPAA approved. That seemed to go really well. We started to hire more therapists because we saw an uptick, very much so, and people needing services within our community actually hired some therapists, some of which you know were completely remote and I didn't meet them for a year because of the lockdown and everything. So we were able to pivot. It was hard as a parent and business owner to be able to figure out how to work from home because we weren't having clients in person. So that was a big shift for people making sure you have a safe environment that's also private and quiet, as much as you can possibly do. So we saw a lot during COVID very much an uptick in people wanting services. We also hired several people during that time, so I think we were very lucky to weather it fairly well.

Dr Andrew Greenland: 8:40

And several years down the line you still have a sort of a hybrid approach. You know now that we can still see people in person. We can see people in person these days, but I just wonder whether the demand for online services has kind of stayed and people want to have care delivered in that way, even after lockdown finished.

Brooke Buck: 9:02

Yes, most of our therapists do some sort of hybrid approach. We do have several that are completely telehealth, given where they are located. So we are seeing very much a trend of people people, more and more people wanting to be in person, and I've owned a lot of facebook different groups for lpcs, therapists in general, virginia-based, around the us, world-based and they have also the comments I read a lot recently they have also seen an uptick of people wanting in-person services again. So it's very much both but someone that started services with us living in possibly a rural area. They're going to probably most likely stay telehealth just because they don't want to have to then commute, and we wouldn't require that of any of our clients if they don't want to. Some it depends on the day. With so many people going back into the office, we are seeing it becoming a little more difficult for scheduling purposes. So I'm really working with a team to be flexible with those individuals while they are employed.

Dr Andrew Greenland: 10:06

And what's the dynamic like? I mean obviously the nature of the work that you do and it's really intense and trauma focused stuff. How does that dynamic change, you know know, in the remote setting versus in person, and how do your team show up for both? I mean, how do they show up for somebody who's online, where you kind of lose a little bit of that connection, versus in person?

Brooke Buck: 10:29

we try our best to make sure we're building rapport with our clients. We're open with our clients. Is this working for you? Is clients Is this working for you? Is this not working for you? Do you need, instead of a telehealth provider, do you need an in-person provider? And sometimes, depending on what they're going through and their level of care, their level of need, they do need to see someone in person. For example, the younger aged individuals, children, teenagers, even we really prefer to see them in person because that's so much more impactful. Like you were talking about, some people actually prefer telehealth as adults. So it really just varies the personal preference. So we try to be flexible with everyone. We do with medication management, especially if someone needs to be higher level of care, needs to be seen a lot more regularly, we do encourage in-person services and the younger they are, we do encourage in-person services.

Brooke Buck: 11:18

Just, to make sure it's the best fit for everyone.

Dr Andrew Greenland: 11:23

So what's going really well for you and your team at the moment in the practices? What's something you're kind of really proud of that you've managed to do?

Brooke Buck: 11:30

We're really proud of we were just awarded the best counseling therapy practice for Northern Virginia by Virginia Living Magazine. So we're very, very proud of that. So we kind of feel like we're doing something right. So we were voted that and then it just came out this month.

Dr Andrew Greenland: 11:45

And what is it you think that you do, over and above, perhaps, what other people in the space are doing? What do you think was the thing that made you win the award? What was the thing?

Brooke Buck: 12:00

Well, I think, hopefully we're providing good services and people want to continue working with us and we are able to retain our clients that are still needing services, that they feel that they have a rapport with us. We have built that connection and that's really important because when someone comes to therapy, they're probably not in the best headspace, unfortunately, because they don't come to see us because you're doing really great. So we kind of have to take a step back and be like they're coming for services, they're coming for support and what can we do to make sure we are doing what we need to build that rapport to help them, to break things down with them and involve them in their treatment process. We do treatment plans with our clients so they know their goals, just like we know their goals, so they're not coming in every session and saying, okay, well, I did this this week and this happened over the weekend. We're trying to make sure we tie it to those goals every session, at least one of them, and this goes for all ages.

Dr Andrew Greenland: 12:49

Brilliant. What part of running a multi-state practice has surprised you the most?

Brooke Buck: 12:53

Obviously, you've been doing this for a while, but what's the things that surprise you about this whole operation? It's a lot of juggling. The bigger it gets, it can be a lot to manage and a lot to support. So we're not. We only have one physical location, but we are seeing clients in a variety of different areas and different states. So it's just continuing to make sure I check in with myself when are we at? What does the practice need? Do we need to shift? For example, our creative director is now finishing up graduate school to be a therapist, so we're definitely going to have to be shifting. Do we outsource things now? Do I take more on administratively? And where do we balance? Because we are an insurance-based practice? Unfortunately, we're a dying breed being an insurance-based practice.

Dr Andrew Greenland: 13:40

Got it and how do you maintain that sort of consistence, culture across locations? Like you said, you've got one physical location, lots of means of patients accessing your colleagues, but how do you kind of maintain the culture across your business?

Brooke Buck: 13:57

Culture with the team.

Dr Andrew Greenland: 13:59

Yeah, yeah.

Brooke Buck: 14:01

Actually we try to do virtual team building exercises and events. We actually have one coming up, not this Friday, but next Friday we're doing a murder mystery virtual experience. So we try to do those to continue to build team morale, check in with each other. We have monthly meetings, we have lunch and learns, to make sure that we're continuing learning and engaging and that we have that connection with each other. Also, with the group supervision and individual supervisions or so with the group we were able to come together, collaborate. I'm struggling here. I had a win here. This person had a breakthrough. I'm so proud of them. So we're trying really hard to make sure no one's feeling like they're isolated on a little island.

Dr Andrew Greenland: 14:41

Got it. You talked about your award, which is amazing, well done. But on the flip side, what's sort of being hard or challenging in the business? What things are operationally cause you sleepless nights or things that you worry about?

Brooke Buck: 14:56

Insurance Insurance being an insurance-based practice that we do accept several different insurances and we've added throughout the years. There are some insurance companies that are really wonderful to work with who are reasonable with their rate increases for us annually. Or if we do a value proposal once a year and send it requesting a raise, they really take that into consideration and they work with us. And then we have the insurance companies who refuse. They won't change their rate, they haven't increased their rate in eight years, so actually we're taking about a 30% pay cut from that insurance company.

Dr Andrew Greenland: 15:33

Wow.

Brooke Buck: 15:33

And they are a dominating factor on the East Coast.

Brooke Buck: 15:37

So we are constantly trying to see what we can do to make things work. We will take insurance, we will always accept insurance, but that can be a big barrier. The insurance company's denying claims, the insurance company's not increasing any of our rates, because it's kind of like how I describe it to people Imagine the insurance company is your boss. So we are, as practitioners, going to our boss, the insurance company, saying, hey look, we've done all these great things and served the community. We would like this, we would like a raise, and they just either ignore us or say, no, we're not making enough money.

Dr Andrew Greenland: 16:14

It's funny because I'm UK-based. We don't really have this kind of thing going on quite so much. In the uk. We have a health service where everything is free at the point of delivery for patients in the service, um, but everyone I talk to in the us the insurance thing is always crops up on these calls. It's really, really interesting. I mean, how do you navigate this? I mean, do you have you found solutions to kind of work around all these different things, because you've mentioned some nightmare things in terms of things that affect your income as a practice? How do you kind of get around all of this?

Brooke Buck: 16:44

We try our best to increase our referrals with the other insurance companies as much as we can. We file complaints to get the insurance company that I was mentioning speaking about that unfortunately I will not name. We try our best to see what we can and can't do. We try to cut our costs in other areas. We try our best to make sure we're aware of it and we're not going to just go away.

Brooke Buck: 17:08

We're going to keep doing the value proposals. We're going to keep filing the complaints. We're going to keep doing what we need to do to make sure that we're trying to change what happens with a lot of practices and several that I know of personally that I have colleagues, friends, that own practices. They've just said no, I'm not dealing with it. So then they go self-pay and a lot of people can't afford self-pay and I know, being in the Washington DC area. There are a lot of high-paying jobs, highly educated individuals, but that doesn't represent the whole population. There are a lot of people who can't and unfortunately, with the political climate that we're in, more and more people need to be able to use their insurance or be able to have a lower sliding scale rate because they've unfortunately have lost their jobs or gotten laid off or ripped.

Dr Andrew Greenland: 17:56

Got it? Have you noticed anything in terms of client expectations that you see coming through, and how has your practice sort of managed to adapt for what you're seeing, what people are asking for?

Brooke Buck: 18:10

Client expectations you know, making sure that you have in-person availability. They want to be scheduled fairly soon, especially because they have something probably going on right then and there. So we try to get people in as quickly as we can, not having them wait months. At some points We've had to, unfortunately, do that, trying to make sure we offer different services for the client's expectations, everything from like the medication management side to maybe a provider that sees young children, as young as three. So we try to make sure we're offering those services that we're seeing people want and request.

Brooke Buck: 18:43

In the area. We've also started to offer groups. We've done a parenting group. We've also done a women's empowerment group that people have really taken hold of and really seem to like that we also have. Every once in a while we'll survey our clients, our population that we have right now that we're serving, and like what are you looking for? What would you like to see? What is the most important thing to you right now as far as if we're mental health and therapy, so we do that as well. That way we can get some feedback from them. So we kind of know do we need to pivot and turn somewhere else?

Dr Andrew Greenland: 19:19

interesting on that point. Are there any sort of services that families are asking for now that they weren't sort of two to three years ago?

Brooke Buck: 19:25

adhd and autism are definitely coming up more and more. It wasn't that it didn't exist prior. People are questioning, they're asking and we're seeing links and we're like okay we might need to consider getting tested. We also see that in adults, so we are seeing a big push from families. It's like what is going on with my child. Is it anxiety or is it something such as ADHD that you know is creating that anxiety for that person? We are seeing a lot more diagnosis in autism and autism spectrum, adhd, the neurodivergent population.

Dr Andrew Greenland: 20:04

Is there a? I mean certainly in the UK the wait time to get an assessment in the health service is around two to three years. I mean, do you have anything like that level of burden in the US or because of the? I don't know, because there are more practices doing what you do? Is that something that you can service?

Brooke Buck: 20:22

We don't necessarily do as much in testing in-house. We are constantly networking. I have a networking event Friday with other therapists and oftentimes when I go to these networking events I will meet individuals who just started a practice with medication management. So we can refer people there and they can do testing. Or we don't necessarily. There might be something that we don't necessarily do. So I'm constantly linking up with people in the community other therapists, other practices. What do we need to do to collaborate? Because we want someone to feel, like they come to us, even if we can't necessarily support them at the moment, that we can try to link them up with someone who can.

Brooke Buck: 21:01

So these networking events are so important to go to in our community to make sure that if we can't support someone, we can figure out who can. And I have my nice little book of business cards with everyone in there, so I can look through great.

Dr Andrew Greenland: 21:14

Are there any um in terms of you managing this as a business? Are there any particular metrics or things that you look out for to kind of gauge how well you're doing the kind of things that you focus on as a business owner?

Brooke Buck: 21:27

I just want to make sure my staff is happy. So if they're happy and I can give them the rate increases annually that I would like to, I consider the business doing good.

Dr Andrew Greenland: 21:37

So at the end of the day.

Brooke Buck: 21:38

I just want to make sure we have a little bit of reserve in the bank accounts. I just want to make sure the staff is happy, make sure that they are feeling seen and heard checking on them with their mental health. Feeling seen and heard, checking on them with their mental health, Do they feel?

Brooke Buck: 21:54

we do live in a very pricey area, making sure that they feel that they can afford the things that they need to be able to have a place to live, eat all those things. So at the beginning of the year I did ask everybody. I was like how are you feeling about what you earned last year? What would you like to see this year?

Dr Andrew Greenland: 22:15

Let's talk about if it's doable what would put you in a good position, financially Brilliant, and then thinking about the future, so thinking about the next sort of six to 12 months. What are you hoping to build or evolve within the practice?

Brooke Buck: 22:25

Well, actually, Cloudbreak Therapy is partnering with TheraGrace and that is a 501c3 mental health nonprofit that I've started. That's going to start with the funding we're fundraising right now to be able to fund people who can't afford therapy services, balance the two of those so that we can start to for the people who have lost their jobs, having other financial hardships, that they will still be able to get services, because we'll find a balance between practices in the area for their providers to see individuals. We'll offer a kind of a scholarship program that will help with the payment of therapy for individuals for X amount of time.

Brooke Buck: 23:11

So we're in the process of fundraising, working with the board, getting everything kind of up and established.

Dr Andrew Greenland: 23:17

Brilliant. I was going to ask you. I was going to ask you if you could wave a magic wand and solve one issue. What would it be? I think the answer is going to be the insurance Is there. Is there anything else, though? That is like a sort of a block in what you try to do for your patients.

Brooke Buck: 23:32

I would love yeah, I would hit the nail on the head Insurance. I wish the insurance would accept mental health as much as they do physical health in the United States and work with us to make sure we're paid a reasonable rate for our areas. I would love that to be more accessible for people and basically making sure that if someone wants services, they don't have barriers to get services. We want to make sure that they feel that I live in this area, there's no therapist, I can't get services. We want to work with those individuals. Yes, you can. What's your barrier? Is it finances? Is it your location? What is going on that you aren't able to get services? And also reducing that mental health stigma. That therapy is not helpful. It's not helpful to kind of work on yourself. It can be very generational at times.

Dr Andrew Greenland: 24:24

Brilliant Brooke, thank you so much for spending the time talking to us today about you, your business, what you achieve, what you've, what you've built really, really interesting to hear. Really interesting to hear about the whole burnout thing and how you look after your staff, um, and also to hear about the, the common stumbling block of the insurance, which seems to be a universal us theme that I'm hearing on these calls. But it's interesting because we're all trying to learn from each other as practitioners and it's useful to know what challenges that other people have in different parts of the world in different space. But thank you so much for your time today. Really appreciate your openness and giving us a sort of candid insight into your clinic great.

Brooke Buck: 24:59

Thank you so much thank you.