Why Wait?

By Jeff Levy

As the new year approaches, I review the past year for lessons learned and changes I’d like to carry with me into the coming year. I also use the end of the year to talk with my clients, the Live Oak community, and colleagues who seek me out for consultation or discussion, about how to create a clinical practice that is effective on both micro and macro levels.

While the ten strategies listed below are specifically for therapists, some of them may be generalizable to many of us. And, those that don’t necessarily generalize to other types of work may afford those of us who are clients a better understanding of why therapists have certain policies or structures.

1.  Use the first session of the new year to review policies and procedures about your practice.

Even if we’ve had clients sign an informed consent or statement of agreement about our policies and procedures when we began our clinical work, often times our clients forget what was on these documents and/or we become more lax in enforcing our policies.

By reviewing policies and procedures of our practice at the beginning of every year, it becomes standard operating procedure and provides an opportunity to reinforce the structures of our practice. I typically have my clients sign a statement of agreement each year and have found this to be a helpful reminder to me and to my clients.

This is also an opportunity to introduce any new policies we’ll be implementing, including any fee changes, schedule changes, or cancellation policy changes.

2.  Consider a cancellation policy of 48 hours rather than 24 hours.

While many people consider a 24 hour cancellation policy to be standard, in our work, even with 24 hours notice it is challenging to offer an open slot to another person when a cancellation arises. Requesting 48 hours notice for cancelled sessions gives us time to offer the open time to one client and, if that client isn’t able to accept the open slot, to offer it to another client, and sometimes even another. I’ve rarely had my clients react negatively to this policy when I explain the rationale.

Of course, I do not charge clients who cancel due to illness, incidents of extreme weather, or family emergencies. Each year, I also offer clients one missed session at no charge and use that as an opportunity to remind them about my 48 hour cancellation policy. I’ve found this increases a sense of good will and shared responsibility. At the same time, cancellations have actually decreased.

3.  If you facilitate a group, consider implementing a policy where group members are charged whether or not they are in attendance.

When I facilitate groups, I am clear from the time of the intake appointment, that group members are charged for each session whether or not they are present. This differs from my cancellation policy for individual/couple/family sessions for several reasons.

First, when an individual/couple/family cancel a session with 48 hours notice, they provide an opportunity to offer that time to another client. When a group member cancels, that “slot” cannot be offered to another person because the person canceling is part of a group.

Second, if we consider how other groups operate, for instance a course or class, when someone is not able to attend a particular class or course session, a refund is not typically offered because the person is paying for the entire course (unless it is structured in a way that allows registration for sessions separately—which is not possible in a therapy group).

Third, and most important, charging for sessions whether or not the group member is present decreases absences and increases safety, predictability, and commitment to the group. I have spoken to some colleagues who facilitate groups and do not have this attendance policy and instead, for example, have the same 48 hour cancellation policy.

They’ve shared that some group members haven’t attended group for weeks at a time because they call with 48 hours notice for each absence. They’ve told me that their group is “full” (the maximum number of slots are occupied), but their attendance from week to week is closer 75% of that maximum number. Such irregular attendance can significantly impact group cohesion and the extent to which the group can move into more difficult and/or intimate material.

While it may be challenging to implement and enforce a policy around groups and attendance, I’ve found such discussions help tip the scale of ambivalence. And such a policy actually empowers the individual member to make a choice about attendance and empowers the group to hold individual members accountable for their involvement.

 4.  Establish a set schedule and offer times to clients only within the hours of that schedule.

When we work independently or in a group practice, it is often tempting to reschedule clients or to schedule new clients at times that may be outside of our preferred hours or intended schedule.   If we determine what our schedule will be and only schedule (or reschedule) clients within those hours, we are less likely to feel resentful and, at the same time, convey to our clients that our time together is a priority.

In the signature block of my email and in my informed consent document, I share my work hours with my clients. In this way, people know the parameters of my work time and are less likely to be surprised when I am not able to accommodate a rescheduled appointment outside of my regular hours. Of course, there are exceptions when there are emergencies or special circumstances.

The only exception to this kind of structure might arise when we are just starting as a therapist.  When beginning to develop a clinical practice, we may need to be more flexible around scheduling to accommodate a number of clients and build to capacity. Once we are seeing the desired number of clients, it is then possible to “massage” our schedule to one that is more consistent and predictable.

5.  Consider consolidating the scheduling of clients you see on alternating weeks. You might even consider designating specific times for clients you see on alternating weeks.

When a client I have been seeing weekly asks to see me on alternating weeks, after some discussion about the rationale and determining if this is in my client’s best interest, I’ll inform them that I have specific times reserved for people who see me on alternating weeks, and that typically, the “off weeks” for one client are the “on weeks” for another client.

In coordinating clients who wish to be seen on alternating weeks with other clients who wish to be seen on alternating weeks, my schedule is more consistent and predictable. And, my clients understand that if they cancel, they cannot assume the same time is available the following week. I will still work to find another possible time to reschedule a canceled appointment. I just cannot promise the same time the following week.

6.  Identify a block of time and/or part of a day each week for rescheduling clients and/or scheduling clients who travel for work or have inconsistent work schedules.

By reserving time each week specifically for rescheduling or for clients who see us irregularly, we’re more likely to find time to reschedule. At the same time, we are less likely to flex or bend our schedule to accommodate people at arbitrary or difficult times.

While this may sound somewhat rigid, I’ve found when I haven’t designated a block of time for rescheduling (which for me is typically on Fridays), I am more likely to schedule early in the morning or late at night to accommodate my clients. When I’ve done this too often, I’m more vulnerable to resentment and to feeling depleted. I’ve also found I assume more of the responsibility for finding a time to reschedule.

Most of my clients know that Fridays are my “flex” days and when other times become difficult, they will often ask what I have available on one of those days if scheduling or rescheduling becomes problematic. I make it a point, however, not to schedule weekly or bi-weekly clients on Fridays. On weeks when no one cancels or reschedules, I’m able to have an extra day off and a possible extended weekend.

7.  Use voicemail, email, and text messaging sparingly and judiciously. Be explicit with clients about when you will respond to communication that occurs outside the time(s) of in-person sessions.

While it may feel convenient to communicate with our clients through email and text messaging, the implicit meaning in an email or text can frequently be lost fostering misunderstanding and unnecessary conflict. And, often email and texting are not HIPAA compliant and therefore compromise confidentiality.

With new clients, and with occasional reminders to existing clients, I’m explicit about when I’ll respond to emails, voicemails, or text messages received between sessions. In my outgoing voicemail, I share that I will return calls within two business days. In my email signature block, I state that I will return emails within three business days. While I may respond sooner, I don’t want to establish an expectation that I respond immediately.   Setting up this type of expectation can be exhausting and might also reinforce our clients’ sense of not being able to sit with discomfort and/or anxiety.

Let clients know, in writing, whether email communication or text messaging is confidential. If it is not confidential, be sure clients understand this when sending an email or text message. Since I am not an expert on what constitutes HIPAA compliant communication, please take an opportunity to consult with such an expert about the confidentiality parameters around communication.

Inform clients that you will not respond to “emergency” emails or text messages. Consider having a disclaimer in your own email signature block that indicates how frequently you check email and/or what to do in the case of a clinical emergency.

When clients cancel, do not inform them of a financial charge or consequence to the cancellation via voicemail, email, or text. These kinds of potentially charged conversations are best reserved for in person, or at the minimum, “live” phone communication. When we avoid having these conversations directly, we reinforce patterns of avoidance and also run the risk of rupturing a relationship without the opportunity for repair.

Avoid responding to emails substantively. When possible, inform clients ahead of time that emails that contain anything more than scheduling information will be saved for discussion at the next scheduled appointment. I’ll typically tell clients ahead of time that when I receive email that is not scheduling related, I’ll respond with an email stating I received the communication and will hold it for further conversation.

I’ve had colleagues tell me about email communication they’ve had with a client that sounds more like a conversation during a therapy appointment. Engaging in such communication dilutes the in-person relationship and, at the same time, can take up an enormous amount of time, increasing the likelihood of feeling overwhelmed and/or resentful.  Even though we live in a world where more and more communication occurs electronically, I still believe the best type of therapy occurs through live, real-time/immediate interaction.

Being thoughtful and judicious about communication that is not live and/or in-person allows for clearer boundaries and for a therapeutic relationship less vulnerable to unproductive and/or unnecessary projection.

8.  Write a progress note or brief summary of each session immediately after the session ends.

Whenever possible, I’ll write a progress note immediately after a session and before the next session begins. Since implementing an electronic health records system, it has been much easier to write my notes in between sessions.

Writing immediately after a session allows me to write more specifically and accurately about the session and also decreases the likelihood of having multiple notes to write at the end of the day. I’ve also found it easier to procrastinate when I have multiple notes to write and, when this happens, I might have several days worth of notes to write at one time. When this occurs, my notes are almost always less specific and less accurate.

9.  Leave your office for a few minutes after each session and before the next session begins.

Whenever possible, after I’ve written my progress note, I’ll leave my office, walk down the hall, get a drink of water, or simply walk down the hall and back. If my next client is waiting for me when I open the door, I’ll invite the client into my office and to make themselves comfortable while I take my “walking break.” This break serves several functions.

For me, leaving my office for even 1-2 minutes affords an opportunity to clear my thoughts, move my body, and “re-set” my psychological and physical system, making me more available and accessible to my next client.

For my client, having a chance to enter the space, sit down, and become comfortable provides some time to settle in and ready themselves for the session. It also avoids an abrupt start that can occur when I invite someone in and we both sit down at the same time, looking at each other while we are both orienting to the beginning of the session.

10.  Establish some type of ritual that punctuates the end of your day.

By creating some type of daily ritual to end the day, I’ve found that I’m better able to leave work at work, clearing my head, heart, and body of some of the stress that has accumulated throughout the course of the day. I’ve experimented with a number of different ways to punctuate the day. Some examples include:

  • Playing a song or listening to music, perhaps something familiar and/or inspiring while readying the office for the following day.
  • Fluffing all the pillows/furniture, cleaning off all surfaces, and emptying all garbage cans.
  • Checking email and responding to any communication that needs a response so that it is not awaiting our attention at the beginning of the next day.
  • Making a list of any thoughts or insights we’ve had over the course of the day. Writing these down helps “let go” of any nagging ideas. A variation of this might be to write down three challenges and three successes we’ve had over the course of the day.
  • Sitting on the floor, on a pillow, or on a comfortable chair and engaging in several minutes of meditation and/or mindful breathing.

While it may initially seem forced or contrived to establish such a ritual, by engaging in some practice that symbolically ends my work day, I’ve found I am better able to engage in my evening or weekend and am less likely to feel an accumulation of work-related stressors over time.

Why Wait?

We don’t only need the new year to consider ways we can structurally change or enhance our clinical practice. I have found that we don’t often intentionally look at the way our work is structured and how that structure impacts how we feel about our clinical work, the quality of our clinical work, and how we experience our non-work time.

I’d like to extend an invitation to all of us to re-examine how we structure the work we do. Are there things about the way we work that we once used to think about but over time have forgotten or relaxed unintentionally? Are there structural changes we’d like to make that will enhance our clinical work while also enhancing our non-work time? Are there aspects of how we structure our practice that we’ve been reluctant to change for fear of how our clients may react?

Even a small change can have a large and lasting positive impact. December is a perfect opportunity to establish a ritual to punctuate the end of the year and to welcome the new year with personal and structural changes to our clinical practice. The list of possibilities is endless, though I hope we’ll find one or more of the ten strategies listed here a catalyst for transformation.

When it’s time to change you’ve got to rearrange, Move your heart to what you’re gonna be, Sha na na na na na na na, sha na na na na, Sha na na na na na na na na, sha na na na na

—Raymond Bloodworth, Billy Meshel and Chris Welch
(performed by Greg, Marcia, Peter, Jan, Bobby, and Cindy Brady)

Written by Jeff Levy, LCSW, CTRS

Published on December 4, 2017