Tuesday, May 24, 2016

Practice Model

Chapter Two
Practice Model
            Having established a professional identity, the next step is articulating and operationalizing a practice model, the structure of each session supported by your theoretical orientation in a way that can be explained and documented.  It starts with education, training, and practice in the different therapeutic modalities; individual, couple, family, and group, and experience with the multitude of psychotherapy theories.  We watch and learn the different intervention strategies; attachment-focused therapy, cognitive-behavioral therapy, motivational interviewing, narrative therapy, play therapy, solution-focused brief treatment, etcetera. We may describe our theoretical orientation as eclectic.  However, developing this orientation entails both adopting evidenced-based practices shown to be effective with specific issues and carrying them out with fidelity and embracing practices that feel comfortable in our delivery.  This is where your personal learning style comes into play.  I do best reading about interventions and putting them into practice.  Others are visual learners who like to see the practice modeled.  Certification in the delivery of several practice models like Dialectical Behavioral Therapy and Eye Movement Desensitization and Reprocessing require hours of training and supervised practice.  This still may not provide a road map for each session.  Rather than feeling “eclectic” I choose to pick interventions appropriate for the situation with a framework to support the art and science, use of self and personal style that has become my practice model.
            Having set the first appointment by telephone or e-mail, and that is the only purpose for which I use either, and directing the client to my website for directions and to complete, print, and bring the initial paperwork, I greet the client in my waiting room with, “Are you here to see Mike?”  I learned this from another therapist as a way to protect the client’s confidentiality.  Similarly, besides being unprotected or un-encrypted, telephone and e-mail messages are prone to misinterpretation which I learned the hard way.  Clients may find it convenient to let me know what is going on with them and the family which can be very helpful.  But my attempts to provide feedback or guidance in a quick written response are too easily misunderstood and instead require the clarification and processing possible only in face-to-face communication.  The welcome is followed by an invitation to be seated and a casual conversation about directions, the parking, and restrooms and any other needs like disability access and comfortable seating.  For children, in the presence of parents to model, I provide my expectations of their behavior; where they may sit, the volume of their voice, books they may use or not use in the waiting room.  I repeat my expectations for their behavior in my office; where they may sit, their tone of voice, what they may use if they ask, and I invite them to take a tour of the office to increase their comfort.  This is after I have prepared parents to include their children in subsequent sessions.
            The first session allows the client to explain their reasons for seeking service often repeating some of the information they have shared in the initial telephone call scheduling the appointment.  I acknowledge the concerns but do not pursue them much further before I have established informed consent and because I do not want the client to disclose sensitive personal concerns before we can establish a safe professional therapeutic relationship, which can lead the client to end therapy before it starts because of strong feelings of vulnerability.  Informed consent includes the education, training, experience, and licensure of the provider, an explanation of theoretical orientation, the benefits and risks of therapy, how the client’s confidentiality will be protected or breached in the case of mandated reporting and safety risks or limited in the cases of lawsuits against the therapist and collection of fees, how the client may schedule, cancel, and pay for services, and how services may be terminated professionally.  The document and the conversation include who may provide consent, how the client may communicate with the therapist, other services that could be adjunct or alternatives to therapy, and grievance and appeal procedures for dealing with complaints and disagreements.  Those are the basics.
            Articulating these policies takes some thought.  For example, I specifically started asking parents whether they are parenting with a partner, and for families of adoption and divorce, who has legal custody of the child client.  I ask parents to produce proof of these legal arrangements and for both parents to sign the consent for treatment.  Without it I have had to terminate services with a parent and child whose non-custodial parent with legal rights did not consent to the child continuing therapy.  Children 12 and older may consent to their own treatment for substance and sexual issues but there are limits to confidentiality here, too.  It also saves time to ask clients to determine what kind of mental health benefits they have and whether I am on their specific insurance panel.  I have spent too much time on the telephone determining whom to bill or dealing with the denial of claims which calls into question professional and therapeutic boundaries.   Putting it in the hands of the client to seek the authorization for treatment and following up on billing is a clinical decision literally requiring clients to buy in to the process.  Just like making the initial telephone call, keeping appointments, and showing up on time these are measures of client capabilities and commitment.
Clients also make a statement when they fail to show up for appointments, sometimes a statement they are not able or willing to deliver to the therapist in person;  the issue is something they can address on their own, the problem is not severe enough to disrupt a busy life, the therapist is not a good fit, another form of help is better.

“I’ve been a social worker for 17 years, licensed since 2004, in private practice 10 years.  I work with individuals, couples, and families, many adopted families since my background is in child welfare.  With families I work with parents and children together.  And, I focus on relationship, not behavior, except perhaps parent behavior.   I consider the parent to be the co-therapist and I coach parents in addressing concerns with their children.  Because of this I do not keep secrets between parties, that is, if a parent or child shares something with me I will use my best professional judgment in determining whether, when, and how to share it with the other people.  Specifically, I do not meet with children alone, and children do not have a right to confidentiality separate from their parents.  I will tell your child I do not give hugs, we are not friends.  I represent this as a professional relationship.  They get their hugs from their parents, so handshakes and high-fives with me will do.  I do not give or receive gifts.  I am not a friend.  Friends are the ones who come to your house for dinner.   I will not come to your home or school without your consent.  If we see each other out in public I will not acknowledge you unless you notice me first.  That is to protect your confidentiality.  You are welcome to leave me a voicemail or e-mail sharing events or concerns but I will address those questions in session so we can make sure we understand each other.  If someone other than you calls me about you I will not acknowledge you as a client.  What we talk about in the room stays in the room.  I document our sessions to remember what we have done.  Some things cannot stay secret.  If a child or older person or disabled person or animal is hurt, I have to tell.  If someone is going to hurt themselves or someone else, I have to do something about it.  I will explain this again with your child.  You are welcome to bring other family members into session if you think it will help.  If there are others you think it would be helpful for me to talk with such as a psychiatrist or teacher or another therapist, I will ask you to sign a release of information for me to do so.  I may consult with other therapists about our work, but I will preserve your confidentiality when I do so.  I keep client files for 10 years after we finish our work together then I destroy them.  I keep then locked and encrypted.  I consider therapy has a beginning, middle, and end.  I meet with parents three to four times before bringing the child in and often without the child after we start.  It is important to understand the work adults do will benefit the child.  You may even decide to spend the session for you.  I am not the parent and children are not dry cleaning that can be brought into an office for 45 minutes to have their behavior “cleaned up”.  I expect to have a friendly relationship with the child but it is OK if they don’t like me.  I intend to strengthen and reinforce the parent-child relationship so I try to put myself alongside or behind the parent in those interactions.   My appointments are 45-minutes long.  You may reschedule or cancel with 24-hours’ notice. There’s a rhythm to therapy.  We will work and play in session understanding that play is the work of children.  This first meeting allows you to decide whether you feel comfortable enough to continue with me, and I get to decide whether I think I know enough to help.  Once we decide we can develop a plan.  Sometimes, it takes just a few sessions, sometimes months.  I have also worked with families off and on for years as children grow and challenges present themselves.”
            The rest of the first session is devoted to engagement, assessment, risk assessment, mental status examination, and suggestions for adjunct resources like books, classes, and support groups.  Engagement happens as I listen and restate the major concerns of the client, empathizing with challenges and appreciating areas of strength.  I take this initial assessment directly from my intake forms which the client has either reviewed or completed.  Here I have included questions about pertinent medical and mental health history, previous counseling and psychotropic medications, and developmental and family history.  I use a checklist that includes symptoms of depression, anxiety, and other conditions and specific risk assessment questions including substance use, self-harm and aggression toward others, relationship safety, and child, elder, disabled, and animal abuse.  I included parent behavioral concerns like stealing, lying, aggression, and manipulation and added a severity scale of 0-10 so the intake assessment also becomes an evaluation tool that can be reviewed as treatment progresses.  Having started with an open conversation I use these forms as a tool to cover these specific questions which makes asking them more comfortable and normalizes them as part of the therapeutic process.
            Payment is also part of the discussion in the first session.  After all, making a living is the point of private practice.  Discussing money feels uncomfortable to many, but it too is of clinical concern, part of informed consent.  We put a price on our service that says our training and experience has value.  The client who sees value in our service is more likely to be committed to the work we do together.  We ignore the subject to the detriment of both the client and our own practice.  It takes some development of professional identity to say, “I charge $120 for a 45-minute session and I have also agreed to receive insurance payments if you choose to use your benefits.”  It takes some confidence to provide a bill, wait for a check, or process a credit card payment in the first session right after discussing weighty personal issues.  Perhaps it feels like it cheapens the interaction.  Instead, it says, “You have just received something of value.  You are worth it.  I earn my living this way so I can continue to be here for you next week.”  Discomfort often leads us to ignore the subject to the detriment of the client’s treatment and the health of our own business.  It says, “What we have done is not a big deal,”  “Or, I can take care of it later, my client will remember.”  Often the way clients manage money is diagnostic.  Do they forget to pay us and fail to follow through with other commitments?  Are they angry with others about money and have difficulty taking responsibility?  For us, money issues can be triggering leading to counter-transference with clients.  Can we offer unconditional positive regard if we are not so subtly resentful of the client not paying us?  Do we put out the same effort or spend the same time with a client who uses Medicare as one who pays cash? 
The same goes for ethically billing insurance companies by providing accurate dates, times, procedure codes, and diagnoses, and collecting co-pays and no show fees from clients.  This continues to take practice as I set boundaries and expectations around payment for services.  I will discuss questions and challenges around joining insurance panels in a later chapter.