“Fat . . . Borderline . . . Retard . . . .”

It is always shocking to me how easy it is for medical and mental health professionals to reduce their clients to less-than-desirable and less-than-accurate one dimensional labels behind closed doors.  I’ve heard excuses that range from minimizing (“oh-he-knows-I-don’t-mean-it”) to intellectualizing (“it’s just a short-hand way to refer efficiently to a particular group of symptoms).

Whatever the reason . . . ignorance, mean-spiritedness, or just plain old laziness . . . if you’ve been tempted to mock a client or speak derisively about a client behind closed doors, you might want to check out Tara Parker-Pope’s post on professionals mocking their clients. It’s one of those things that wasn’t discussed in my ethics classes  but probably should have been.  After all, if we are reducing our clients and all of their complexities to a simple one word label, it’s likely we don’t have our client’s best interest at heart.

Tags: Boundaries, Ethics, Judgment

Miles Halvorson of Fargo, North Dakota  asks,

Is it possible for a psychotherapist to start a private practice out of one’s home, rather than rent office space? What are the drawbacks and limitations?”

Hi, Miles!  Thanks for writing.  You ask a really good question.  The short answer is “Yes, it’s possible” but the longer answer is “. . . but I highly advise against it until you have considerable and varied experience behind you.”  Here’s some questions for you to consider when deciding whether or not to work from home:

Do you have a separate entrance to a professional and private home office and bathroom? You, your family, and your clients deserve a professional and private space in which to do your clinical work.

Where will clients wait to see you? Do you have a waiting room?  In their car?  On your front porch?  Will they have privacy from your neighbors while they wait?

How will you deal with door-to-door salesmen, postal workers and other deliveries that show up while you are in session? Those interruptions actually happen all too often unless you take steps to prevent them.

What plans do you have for dealing with threats or violence? Your unhappy clients, their unhappy spouses, and their unhappy friends can show up.  You need to be prepared with a way to keep everybody safe.

How will you handle clients who have lousy boundaries? Clients will call at 2 AM and they will show up without appointments and they may wander through your home or refuse to leave when they are upset.

How will you handle clients (or wanna-be clients) who decide to stalk you? And, how do you explain to your family and neighbors without violating confidentiality.  (Yes, this really does happen.)

How do you protect your non-work time when you are at home 24-7? Boundaries tend to come with experience  – lots of experience.

How do you protect your client records and your workspace from prying eyes? Will your office be off-limits to guests and other family members?  Even when there are sleepovers and you are needing the extra space?

Are you willing to put in phone lines and designate a computer solely to your work? You can’t expect to appear professional if your phone is answered by a 10 year old or by your partner.  And, neither can you share your computer with others if it has confidential information on it.

What are the tax implications? Yes, there are some financial benefits but there are also some financial costs to officing at home.

Here’s the bottom line . . . . Most clients that seek psychotherapy have a trauma history and most clients with trauma histories struggle with boundaries.  Until you have impeccable personal and professional boundaries of your own and are experienced enough to effectively manage your client’s boundary issues, I would advise you against hanging out your shingle on your own front door.

Related Post:  7 More Considerations for Working Out of Your Home

Tags: Boundaries, Location, Office, Safety

Are you a psychotherapist who uses Facebook and Twitter?  Do you blog or engage in other forms of social media?  If so, you need to consider the sticky situations that you may stumble into without any ill intent.  Here is one article by Dana Scarton in the Washington Post that highlights examples of what I’m talking about.

I’ve begun to look for mental health attorneys to join us here on occasion at Private Practice from the Inside Out to help us tackle some of these choice points in private practice.

Let me know if you think this would be helpful to you and if you have a favorite mental health attorney to recommend.

Tags: Boundaries, Ethics, Social Media

This is the 3rd  post in the series
Reduced Fees, Sliding Scales, and Lessons Learned.
The series actually begins here.

If You Choose to Provide  a Reduced Fee, How Long Should You Do So?

I’ve had clients who were unemployed when they began working with me, so I offered my services at a reduced fee.   Later, when they secured six figure incomes, they continued to pay the reduced fees.

Lesson learned?  Yep . . . .

Lesson #1

My own issues with money got in the way.  Otherwise, when it came to my attention that my clients were in better financial situations, I would have addressed it directly with each of them rather than feeling taken advantage of.  If that is true for you, you have some work to do and a good therapist can well be worth her full fee to get that cleaned up early.

Lesson #2

What is understood to be “less than enough” by one person may appear to be “more than enough” to another . . . and vice versa.  Get really clear about the circumstances under which you are comfortable providing reduced fees.

Lesson #3

Reduced fees need to have time limits.    Unless you are operating as a charitable organization, consider how long is “long enough” to help someone access your professional services. Limits are good for your client and they are good for you.

Lesson #4

If you offer anyone a “good deal,” they’ll probably take it.  Make sure to think through the offers you want to make before you make them.

Drop me a line and let’s talk about if / how you provide services to clients at a reduced fee.  What does that look like in your practice?  Is it working well for you and your clients?

Tags: Boundaries, Fee, Gullible

As I was reading Jung at Heart, one of my new and favorite blogs by Jungian psychotherapist, Cheryl Fuller, I ran across her post on the importance of boundaries in scheduling.

"Wall of Clocks" by rustman / Russ Morris

Check out her inspiration for the post, her own post, and then drop back in here to share your thoughts about scheduling clients and the transition in between them.

Tags: Boundaries

Carla read my post here and wrote in asking:

What do you do when as a result of finding out that you are a counselor, your church now wants you to provide counseling services to members of the congregation? Or the fact that you have taught classes at ministry events, and as a result some of the participants want to come see you?”

"Nice, Small Church" by Speediakal

How flattering!  But, here are 9 things that I consider before deciding whether or not to see members of my own church . . . .

1. Size matters.  I have found that it is difficult to be active in a church whose congregation numbers only 200 and still maintain my privacy.  That, in turn, colors my professional relationship with my client.  He knows more about me (and I know more him) than is always best.  If, on the other hand, my congregation numbers 1000, then it may be relatively easy for me to maintain my privacy and to minimize personal interactions outside of the counseling office.
2. I consider how I will handle it if I discover that my client is sexually or romantically involved with one of the leaders in my church (who happens to be married).  As far fetched as that may sound to you, it is not all that uncommon and it may very well change how you feel about your church home.  It did for me.  And, that’s before my client AND my church leader both wanted to vent to me, wanted me to choose sides, and then wanted me to publicly condone their behaviors to others!
3. I also consider how my own unforeseen weaknesses / foibles in my personal or church life (challenges in relationships, lapses in judgement, my own spiritual practices, etc.) might negatively impact my relationship with my client . . . .  Unanticipated exposure of those things can actually color what happens in my church and with my client.
4. I also consider the possibility that my partner / spouse / friend / child / sibling / parent may want to befriend my client.  That’s a mess in and of itself! And, what will I do if I believe (from my  clinical work) that the relationships with my client might not be good for my loved one?
5. I’ve had clients catch me before I could dash off from church services to “catch me up” on the latest chapter of their weekend disaster.  Do I want to do therapy in the parking lot?  Do I want to act disinterested?  Or, do I want to dread seeing that client every time I enter the church door?
6. I also have to consider if / how I am going to interact with my clients when I see them.  Am I going to speak to my clients when I see them at church?  Am I going to ignore them?  What if my new client sits down beside me on the pew?  Wants to hug me?  Asks me to take communion with her — or just “conveniently” times it so that it happens that way?
7. What if I sign up for a church dinner club and get assigned to the one that my client attends?  Am I going to explain to the host why I had to leave abruptly when my client showed up?  Am I just going to let the host think I’ve lost my mind?  (Yep, that’s exactly what I did as I ran out the back door.)
8. What if I agree to host a Bible study and my client shows up . . . or his wife . . . or someone who eventually becomes his spouse?  Am I really going to ask my client to leave because there’s a dual relationship if he stays?
9. Sometimes clients can be possessive of their therapists (and you won’t always know this ahead of time).  I’ve had Client A  show up “hurt” or mad at his therapy appointment because he had seen me talking to someone else at church.

OK, so I could go on and on . . . . My point is this . . . .  While much of this can make for great grist for the clinical work that you do with a client, do you really REALLY want to contaminate your personal life (and the lives of your loved ones), your spiritual home, and your professional life with this stuff?  Just think about it and, if you do, consult, consult, consult.

Can you think of other questions / situations / concerns to consider before jumping in to provide therapy within your own religious community?

Tags: Boundaries, Consultation, Ethics, Policies and Protocols, Reputation

This is part of an episodic series, The Therapist’s Networking Guide.
To see the previous post in this series, click here.

Donna loves Yorkies.  She has decided that a good way to make new friends is to organize a Yorkie Meetup Group.  That will get her out in the community as well as allow her to meet other Yorkie-lovers.

Donna is also a Licensed Clinical Social Worker who wants to build her private practice. Is the Yorkie MeetUp Group a good way for her to get clients?”

Definitely YES! Meetup Groups, as well as support groups and other special interest venues can be great ways to network.  At these groups you will find other folks with similar interests who are interested in meeting other people.

It’s here that you can really get to know individuals (and, more importantly, they can get to know you).  As other Halloween-lovers get to know you and run across clients of their own in need of your services, they will likely refer directly to you!

Definitely NO! On the other hand, as a mental health professional, you cannot ethically or legally hang out with the Yorkie Group, exchange dog stories, go have breakfast together, and then see someone from the Yorkie Group (now or later) as a client.  Neither can you see their family member or close friend as a client.

How to do it right? Be clear . . . very clear about what your purpose is when you venture out into the community and maintain the appropriate boundaries that go with that particular role.  Whether it is at church, . . . at a support group meeting, . . . at a fundraiser, . . .or at a formal business networking event, it is very likely that you cannot ethically or legally sit on a board of directors alongside your client.  You cannot go to Bible study with your client.  And, you cannot attend a brunch that is hosted by one of your favorite referral sources if your client is also attending.  

Note that ALL of these situations have come up for me.

Tags: Boundaries, Conflict of Interest, Ethics, Liability, Religious Community, Support Group

I feel like I’m slave labor for the agency.  No one tells me how to help my clients.  I’m just left to figure it out on my own.”

My supervisor signs off on my paperwork every week but doesn’t really do anything.  We meet. I describe each one of my cases to him.  And, then we spend the remainder of the hour talking about his family.  THIS is SUPERVISION????!!!!”

How do I get the time I need to actually work with my clients?  The paperwork here is overwhelming and my supervisor is too busy to even discuss it.”

Every year the horror stories roll in . . . .  What’s a new counselor to do?  Having a great experience with clinical supervision doesn’t just happen in a vacuum.  In case your graduate program forgot to tell you, here are  nine things you can do to insure that you have the best supervisory experience possible.

1. Interview several potential supervisors even if you think you already know who you want.  Good supervisors will limit the number of counselors that they supervise so that they have ample time to spend with you.
2. Once you ask someone to supervise you, ask for a written contract with that individual that specifies details of your professional relationship.
3. Remember that supervision IS a professional and hierarchical relationship.  Don’t blur those boundaries and don’t tolerate a supervisor who blurs those boundaries.
4. Schedule regular meetings with your supervisor and make them a priority.  Treat them as you would an appointment with any other professional.  Expect your supervisor to do the same.
5. Your supervisor should make arrangements to be available to you in case of client emergencies.  If s/he is unable to do so, s/he should make arrangements for some other qualified professional to be available in her place.
6. In the event that your supervision is not going as you had envisioned it would, you need to be prepared to initiate that conversation.  Go in with an open mind, state your concerns and ask for what you need.
   

   "Perseverance" by Marcus Smith

7. If you have attempted to discuss the issue with your supervisor and are not satisfied with her response, you may seek consultations with peers.  However, until the licensing board in your state or and attorney tells you otherwise, you are required to abide by the directives of your supervisor.
8. If you are unable to satisfactorily resolve your differences with your supervisor, you may have the option to seek a new supervisor.  However, note that some states limit the number of supervisors that you may use to satisfy licensing requirements.  Check with your specific state to be sure of the rules related to this.
9. Most important of all, if you should need to leave your supervisor behind due to a conflict, take the time for self-evaluation.  Learn what you can about you and about this situation.  It is not something that you want to repeat.

How is your supervision going?

Related Posts

Clinical Supervision and Money Gouging

10 Question You Must Ask Your Potential Supervisor

Tags: Boundaries, Contract, Emergency, Relationships, Self-Evaluation

It took me years in private practice before I learned how to effectively handle clients who stood me up or canceled with less than 24 hours notice.

It took me about the same amount of time to learn how to not open a new issue with a client too close to the end of a session and then end on time.

And, then there were the boundary challenges related to money!

Today, I’m wondering . . . what challenges / solutions have you navigated concerning your boundaries in business?

Tags: Boundaries, Red Thread