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Fairness

Time

Money

Space

Accessibility

Practice

Chapter 14: Nuts & Bolts

Time, Money, Space & Accessibility

This chapter is about the "real" elements in the arrangement between patient and therapist. These elements have a good deal of feeling attached to them since they represent the concrete ways in which two lives impinge in each other. Measured against the backdrop of community expectations, how you handle these factors will send messages to patients and referral sources about yourself. You will reveal much about your competence, your view of yourself, your feelings about patients and referral sources and your personality characteristics. Together these communications will have a profound effect on the therapies you conduct and the growth and shaping of your practice.

Mutual Fairness

In arrangements between therapist and patient, it is obvious that the relationship should be perceived as fair by both parties. Even if your personal values call for selflessness, you will probably find that your own emotions do not necessarily agree. Allowing yourself to be exploited, though it presents a distorted view of relationships to the patient, may be possible while the transference is positive, but when you are being criticized and subjected to anger, even hate, then you will not be able to avoid resentment for all that you have selflessly given. Therefore, the rule is to manage the nuts and bolts elements of the therapy so as to preserve your good feeling during all phases of the work.

At least at the outset, before transference feelings have had a chance to take hold, the patient, too, must experience the relationship as fair. At times when negative feelings enter into the field, you will at least have a history of clean relations to fall back on.

Community Standards

Usual practices governing time, money and other nuts and bolts issues in your community will help to provide a benchmark of what is fair and appropriate. How you set things up and how your patient reacts will in large part be determined against a backdrop of local standards.

Frequency of Sessions

Experience, conversation with supervisors, and one's own personal psychotherapy or analysis are the best places to learn about frequency and length of sessions. In general, frequency determines the locus of the action where sessions are focused. Twice a week or more puts the emphasis on the relationship itself. Weekly or lower frequencies tend to mean that the focus will be on outside relationships and events. Change processes can take place either way, but do require a level of intensity of feeling. I have found that maintaining a rhythm and sense of continuity may also be difficult with less than weekly sessions.

Length of Sessions

Much is learned from spontaneous communications. Very brief sessions may prevent the kind of "idle" conversation that can be key to understanding, or even picking up potential danger signs. Thus, even for medication evaluation I cannot recommend less than 25 minutes. Real exploration seems to require more time. At the other extreme, work with Dissociative Identity Disorder patients works best with extended sessions because it takes time to get started, and there is often a great deal of work waiting to be done.

Money

In managing a practice over years, money is the easiest factor to to adjust. A therapist's value generally increases with experience. At first, the fact that you are gaining experience may make it feel fair to accept somewhat lower fees for your work. This is an area where personal "issues" can make their appearance. Low self-esteem or an inflated sense of entitlement on the part of the therapist may be noticeable in the way you handle money. Beware, because, as described above, even if you chronically undervalue yourself, this will not help the patient and furthermore there is a part of you that knows what is fair, and will be appropriately resentful.

Forthright handling of fees, collections and issues like missed sessions sends a reassuring message to the patient that you are fair, consistent and confident in handling difficult matters. These same qualifications are what the patient will need for the therapy to succeed as well. I will not be the first to say that even where billing is handled by someone else, you should know the status of your patients' accounts, and bring up the subject when there are arrears or questions.

Space

How you arrange your space tells a lot. Patients want to know that you are personally engaged, but they are fundamentally interested in themselves. If the space gives too much personal information about you, it will be distracting to the patient and convey the message that your needs are intruding. If it is very bland or impersonal, your personality will have to fill in the missing warmth. Using a couch really does bias towards dreams and fantasy material. Patients are so different in their reactions and needs that there is little to do other than to seek an average that is comfortable to you, and hope that the patient will adapt. I do recommend a chair for you that is comfortable for long hours of sitting. I find that I often slide the chair closer or farther depending on the situation. Patients need a comfortable place but it is useful to have straight-backed seating available for patients who have spine problems.

Accessibility

The degree of sickness of your patients, the setting, whether a clinic or private practice, and community expectations will create the background for your decisions about making yourself accessible. MD therapists are more likely to be expected to be on call, where other disciplines may assume or tell their patients to go to an emergency room. Policies you adopt tell about you and your approach to your patients, and determine who will be most comfortable with you. Over time, you will see more of the patients you are comfortable with, and that is for the best.

Managed Care

When you become part of a "panel" of "providers" for an insurance company, you and your patient accept constraints on your decisions about how to conduct the therapy. Managed care policies will respond to business interests above others. Outside of any panel, there may be constraints as well, as patients do not always have the resources for the ideal treatment. You remain responsible for your handling of the patient, so you must exercise judgment about when to decline to participate. Whether and how to work within third party constraints must be built on individual decisions and, perhaps, participation in collective efforts to counterbalance the power of organized business.

The "Toilet Tank" Theory of Practice

When the water level drops, the tank fills itself. When the level comes back up, the flow stops. Private practices work the same way. One of the most important factors in patient's decision to come for treatment and to stay is feeling wanted. The degree to which you show that you want the patient will be written in the subtle shadings of your behavior. How quickly you return calls, how you sound on the phone, how you deal with patients who have trouble affording your services, how long patients wait for an appointment. All these factors send a clear message. When you are full, inevitably, your messages will be less welcoming. The flow will reliably slow down. Thus, once full, private practices maintain about the same level over time.

In a similar way, the variety and kind of patients you welcome will determine how your practice fills over time. You may have more control over the character of your practice than you realize. If you let it be known that you are interested in a specific niche service, you will become identified with that subgroup. It is human to want to send you the people you have expressed an interest in. Similarly, the way you respond to referral sources will also have a profound effect. Your welcome, along with the patient experiences that are reported back, will determine repeat referrals. Assuming a level of skill and a clean, confident manner, do not underestimate the power of your personal desire.