From Sam Knapp and the PPA Ethics Committee
The face of psychology is changing. When I entered graduate school in psychology in 1973, Pennsylvania had just passed the licensing law for psychology, although the first psychology licenses were not issued until 1974. Much has happened in the field of psychology since that time.
An older generation of psychologist is now cutting back on services or retiring and passing on the tradition to a new generation. Of course, the process of retiring and replenishing a profession is always on-going. But this shift in demographics is especially pronounced in the last 10 years, especially as the baby boomer generation ages.
Members of this older generation of psychologists
- Felt a sense of satisfaction in the quality of their work
- Felt a deep connection to and responsibility for the well-being of their patients
- Cared about public health and social well-being, and
- Know that a new generation will further their work and, we hope, improve upon the quality of service that we provided.
Practice Tip One: Invest in Your Informed Consent Process.
“Was the patient informed of this ahead of time?” Many times, conflicts occur because the patients did not understand the parameters of psychotherapy, how it was going to be conducted, or the expectations of them before psychotherapy began. When conducting family therapy, for example, were all family members informed about how information was going to be shared (or kept private) before psychotherapy began? When conducting assessments, was the client aware of their right (or lack of right) to the assessment report?
The Trust (formerly the APA Insurance Trust) contains an informed consent agreement that can be downloaded and modified as psychologists wish. It covers the common questions that may arise in the course of psychotherapy. Although the APA Ethics Code does not require psychologists to have a written informed consent agreement that patients sign, it is usually good to use such a written form. It is good to review the informed consent agreement with patients in addition to giving them a written document.
One reason that informed consent is so important is that is shows respect for the patient and concern that they understand the rules governing therapy and that it is evidence of an effort to be fair.
Often misunderstandings occur and these are not always the result of maliciously or carelessness. Patients can be very distraught when they first enter psychotherapy and may fail to attend carefully to all the information given to them. For example, many psychologists will charge patients a fee for cancellations without a 24-hour notice and may include this in their informed consent agreement.
Patients are more likely to view the fee as fair if it was explained to them ahead of time and was included in a written document that the patient signed. Even then, many psychologists will “forgive” the first no-show but will reiterate the policy. Such actions do a great deal to convey the sense of fairness that is so important to all of us.
Practice Tip Two: Strive to Upgrade the Quality of Your Services
Caught in the day-to-day demands of work and family life, it is easy for psychologists to let their professional development slide. Most of us have had the experience of rushing home from a stressful day at work to pick up the kids and trying to be pleasant and appropriately parental toward them. It is not easy. With all these pressures there is a temptation to do the minimum continuing education and let professional development slide.
But it is a bad decision to devalue continuing professional development. We psychologists do not magically get better over time and through experience. On the contrary, some of us may get worse over time and eventually become embedded in less-than-optimal practice patterns. We get better as psychotherapists through the same mechanisms that helped us get proficient in psychotherapy in the first place which is to invest time in improving our skills through study, reflection, feedback, and effort.
Ideally throughout your career span you will not only maintain your competence but expand upon it over time. Remember that by focusing on your professional development, you will be
- Acting in accordance with your values of promoting public health,
- Making your work more rewarding as your skill set improves, and
- Making a good business decision to deliver a high-quality product.
Practice Tip 3: Set Limits and Keep Them
Set limits. It is important to understand your areas of proficiency and to stay within them. Knowing what you cannot do well is just as important as knowing what you can do well.
Keep within your lane. Do not go outside of your lane without carefully thinking through the issues.
Dr. Jeanne Slattery says, “resist pressures/temptations to go beyond your limits.” It is true that the APA Ethics Code allows psychologists to go outside their areas of competence if they are in an underserved areas and services are not available. But decide to go outside of your lane of competence only after careful deliberation.
Practicing within limits means not only selecting patients more carefully, but also setting time limits. You can’t be available to all potential patients and may have to decline some referrals because of time restrictions. It is true that we must sometimes extend ourselves in terms of availability during patient emergencies, but these should be relatively rare exceptions.
No one can be competent with every patient in every session. Competence is fluid depending on the totality of the psychologists’ workload and personal stressors. The best psychologists are sensitive to the drains caused by their emotional labor and adjust their workload accordingly.
Sometimes psychologists exceed their limits because of a misguided understanding of altruism. I value altruism very highly. But altruism should not be confused with runaway compassion or unethical altruism which are actions that on the surface appear altruistic, but when considered in more detail can be harmful or destructive.
For example, we have known of conscientious psychologists who became involved in forensic cases even when they lacked adequate skills to do the job adequately. One psychologist spent hours writing a beautifully written and detailed and comprehensive psychological evaluation for an attorney. The problem, however, was that the report did not address the forensic issues before the court. The report wasted precious resources on generating information that was irrelevant or at best tangential to the case.
Practice Tip Four: Develop Good Practice Habits
One well regarded authority on health care referred to competence as being both “habitual and judicious,” meaning that it involves good habits as well as good decisions. One might refer to the good habits part of competence as professional hygiene. You might be able to get away with not brushing your teeth for a while, but it eventually catches up with you.
When asked what practice habits they thought were important, a group of experienced psychologists offered these suggestions:
Have a standardized assessment protocol for your patients that includes the content of the structured interview, assessments (if any), and your informed consent agreement.
Make continuing professional development a routine part of your professional life.
Keep good notes.
Take breaks during the day. Allow yourself a time cushion during the day. In the worst scenario you can use the time for unexpected clinical demands that may arise.
Routinely assess the extent to which your patients are progressing. Use standardized instruments if it can help you monitor their progress carefully.
- Keep good notes.
- Be sure to laugh and laugh at yourself as well.
- Stay on top of the office finances. If you are having a problem with the finances, then ask for help.
- Finally, it is important to keep good clinical notes.
Practice Tip Five: Address Payment Issues Clearly in Your Informed Consent Agreement
Consider this situation:
A psychologist received a subpoena to testify on behalf of a patient who had also signed a release permitting the psychologist to testify. When asked if she could be compensated for her time, the patient’s attorney insisted that she would be compensated. Later that week she received a check for $15 to cover witness fees.
When she approached her patient about the paltry compensation, the patient was indignant, “How can I pay you anything?” he shouted. “I just had to pay my attorney $10,000!”
So, it looks like this psychologist will be spending time in court, possibly losing hundreds of dollars of income, in exchange for $15. Was there any option that the psychologists could have taken to avoid such a problem?
The way to avoid this problem would have been for the psychologist to include a statement in her informed consent agreement that she may charge their patients for uncompensated time including but not limited to writing reports, attending meetings, appearing in court, and travel time at the request of the patient. Services will be billed at the rate of $XX per quarter hour increment or any fraction thereof. This broad wording covers more than court appearances.
Of course, psychologists can always waive charges if they so choose and most psychologists would not nickel and dime patients for very brief non-covered services. One experienced psychologist wrote, “don’t overly pursue things like cancelled fees, charges for phone calls, and incidental paperwork. It doesn’t endear you to your patients and it really isn’t worth it in terms of effort or finances.” Nonetheless, this language protects psychologists in case a patient makes an extraordinary demand on their time and allows the psychologists to charge the patient for the non-covered services delivered. It also keeps some patients from making clinically questionable demands on their time.
Practical Tip 6: Be Prepared for Difficult Situations
Most days of a psychologist are routine. In the average day 5 or 6 patients may come in for psychotherapy, stay for 45 to 60 minutes, say thank you, and leave. But unexpected and difficult situations can come up quickly.
- Patients may report serious and persistent suicidal thoughts.
- Patients may become disruptive.
- The patient who seemed only quirky at first now appears to have a major personality disorder comorbid with other disorders.
- The incident that the father reported sounds so severe that you must consider a report of suspected child abuse.
It pays to be prepared and to have a protocol ready when difficult situations arise. For example, one psychotherapist has a suicide folder in her desk. It contains, among other things, a brief suicide risk inventory and a checklist when evaluating suicidal patients. Several years ago, she had a suicidal patient and, although the intervention went well, she reflected on what she could have done to have been better prepared for future suicidal patients. Thus, she created her suicidal folder.
The types of difficult events will vary according to the nature of one’s practice. A psychologist working with children can expect a different set of disruptive events than one who works primarily with older adults. Of course, no one can predict all the unusual events that one may experience as a psychologist. Nonetheless, as much as possible, anticipate disruptive events and have an immediate response prepared.
Practice Tip Seven: Develop and Maintain Professional Connections
Psychologists tend to do better work when they are involved with a community of other professionals. This could take many forms such as participating in a consultation group, attending in-person CE programs where participants interact with each other, working in a group practice, belonging in PPA or another professional association (and perhaps serving on a committee), or sharing an office suite with other health care professionals.
These contacts help keep us up-to-date on developments in the field, allow an opportunity to talk about difficult cases, and provide others who can monitor our well-being and allow us to recover from the emotional wounds that are an inevitable part of the work that we do. The benefits of seemingly small conversations add up tremendously over time. Colleagues share reactions to workshops that they have attended, podcasts that they have listened to, or books that they have read.
In addition, friends watch out for each. Good friends feel empowered to tell you when you are ready to step on a cow pie. The problem is that when one is under emotional stress and one’s competence is beginning to degrade one’s competence monitor may become degraded as well.
One of the benefits of nurturing professional contacts is that we can give to others as well. By being of assistance to other health care professionals we can further our goals of improving public health. They can consult with us on their difficult cases and we can keep an eye out for their emotional well-being.
Being in an independent practice does not necessarily mean that one is in an isolated practice.
Practice Tip Eight: Contemplate Your Work Space
- Invest in comfortable furniture. You will be spending a lot of time in it. Your back depends on it.
- Find other ways to be comfortable in your work space. Decorations. A refrigerator and microwave.
- When you choose your furniture and decorate your office, get help from someone who isn't a therapist.
- Use a chair mat. It keeps your carpets nice.
- The appearance of your waiting room is as important as the appearance of your office.