Termination in Private Practice

[dutch2020]

Curious to hear termination policies people have in place working in outpatient private practice. In particular, what are folks doing for folks that don’t reach out for many months and/or for folks with chronic illness, young children, or abnormal schedules?

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[MCParent]

Curious to hear termination policies people have in place working in outpatient private practice. In particular, what are folks doing for folks that don’t reach out for months on end?

Def don’t keep people on for months. You don’t want someone committing some horrible crime while they’re still technically under your case.

I’d suggest a pretty terse policy (eg one email, one call, if no response assume they are no longer interested in sessions and they’re welcome to contact you if they are again or if they’d like referrals elsewhere). Also should not only be in the paperwork but discussed in the first session.

 

[PsyDr]

My limited clinical work is managed by staff. There is an overly harsh no show fee policy. Two consecutive missed appointments and you are out. We send a termination letter with a list of local providers, to avoid patient abandonment claims.

I would suggest that:
1) People who are motivated show up.
2) If I had to guess, you are not really strict on any form of "no show" fees.
3) While excusing behavior feels nice, it is bad for the patient. The analysts have a long line of literature about how providers should not indulge patients. If you're curious, look up psychoanalytic abstinence.
4) Payment is one aspect of motivation. If you charge a no show fee, it positively reinforces their attendance. Example:
a. No "no show" fee scenario. I'm in a bad mood. If I go to my therapist, I have to drive there, think about what I need to discuss, pay her $25 copay, deal with my feelings, be held accountable for any homework I didn't do, etc. But if I just cancel, I save $25, avoid some negative feelings, but can say that I am in therapy, if only to myself.
b. Active "no show" fee: I'm in a bad mood. There are all of the aforementioned negatives to going to my therapist. However, I still have to pay her $25 if I don't come, so it really doesn't matter from a financial POV. Do I go? Drop out? It's only $25.
5) Sickness, children, abnormal schedules are not excuses for any recurrent behavior. It's like when someone says they can't control their rage, but behave appropriately when they are at their job, or around cops. If someone wants to show up, they can at least do a telephone based session.

 

[Sanman]

My limited clinical work is managed by staff. There is an overly harsh no show fee policy. Two consecutive missed appointments and you are out. We send a termination letter with a list of local providers, to avoid patient abandonment claims.

I would suggest that:
1) People who are motivated show up.
2) If I had to guess, you are not really strict on any form of "no show" fees.
3) While excusing behavior feels nice, it is bad for the patient. The analysts have a long line of literature about how providers should not indulge patients. If you're curious, look up psychoanalytic abstinence.
4) Payment is one aspect of motivation. If you charge a no show fee, it positively reinforces their attendance. Example:
a. No "no show" fee scenario. I'm in a bad mood. If I go to my therapist, I have to drive there, think about what I need to discuss, pay her $25 copay, deal with my feelings, be held accountable for any homework I didn't do, etc. But if I just cancel, I save $25, avoid some negative feelings, but can say that I am in therapy, if only to myself.
b. Active "no show" fee: I'm in a bad mood. There are all of the aforementioned negatives to going to my therapist. However, I still have to pay her $25 if I don't come, so it really doesn't matter from a financial POV. Do I go? Drop out? It's only $25.
5) Sickness, children, abnormal schedules are not excuses for any recurrent behavior. It's like when someone says they can't control their rage, but behave appropriately when they are at their job, or around cops. If someone wants to show up, they can at least do a telephone based session.

Can you explain this to the Department of Veterans Affairs? (He says as his telehealth appt "forgot" for the second week in a row and is 10+ min late for session).

To answer the OP's question: I agree with @PsyDr and my experience in PP was that people will push boundaries if you do not enforce No show policies. When I used to be in a PP group practice, there was a no show fee if cancellation occurred less than 24 hrs prior to session. There was the option for the clinician to forgo the fee one time. After that you needed to pay. I know therapists that charged the full session fee if you did not cancel a full week in advance and advised clients that this helped improve their planning skills and underlined the importance of the work.

I have a young child and still manage to make it to my doctor's appts on time. They do not show me grace if I forget. If I cancel, it can be months before the next appt. Surely, they can provide the same level of respect to you. I work with patients suffering from chronic illness with frequent hospitalizations, if they are that sick then they may not be in a place to see you as they have more pressing concerns. If they aren't, then it is a choice.

 

[smalltownpsych]

My limited clinical work is managed by staff. There is an overly harsh no show fee policy. Two consecutive missed appointments and you are out. We send a termination letter with a list of local providers, to avoid patient abandonment claims.

I would suggest that:
1) People who are motivated show up.
2) If I had to guess, you are not really strict on any form of "no show" fees.
3) While excusing behavior feels nice, it is bad for the patient. The analysts have a long line of literature about how providers should not indulge patients. If you're curious, look up psychoanalytic abstinence.
4) Payment is one aspect of motivation. If you charge a no show fee, it positively reinforces their attendance. Example:
a. No "no show" fee scenario. I'm in a bad mood. If I go to my therapist, I have to drive there, think about what I need to discuss, pay her $25 copay, deal with my feelings, be held accountable for any homework I didn't do, etc. But if I just cancel, I save $25, avoid some negative feelings, but can say that I am in therapy, if only to myself.
b. Active "no show" fee: I'm in a bad mood. There are all of the aforementioned negatives to going to my therapist. However, I still have to pay her $25 if I don't come, so it really doesn't matter from a financial POV. Do I go? Drop out? It's only $25.
5) Sickness, children, abnormal schedules are not excuses for any recurrent behavior. It's like when someone says they can't control their rage, but behave appropriately when they are at their job, or around cops. If someone wants to show up, they can at least do a telephone based session.

Completely agree with first point and I use my no show termination policy to weed out the unmotivated. Add in that I also dont take insurance so am already screening for a signifiacnt amount of motivation. I don’t charge no show fees but that also fits with my private pay practice and use social/relational pressure to ensure higher show rate. I also think that a fee would lower the efficacy of the social pressure which is another reason why I don’t charge one. Not disagreeing with your strategy, just offering other perspectives that can be effective. When I am training new therapists part of what I teach is that what works for one clinician won’t necessarily work for another because there are so many variables.

 

[cara susanna]

Can you explain this to the Department of Veterans Affairs? (He says as his telehealth appt "forgot" for the second week in a row and is 10+ min late for session).

To answer the OP's question: I agree with @PsyDr and my experience in PP was that people will push boundaries if you do not enforce No show policies. When I used to be in a PP group practice, there was a no show fee if cancellation occurred less than 24 hrs prior to session. There was the option for the clinician to forgo the fee one time. After that you needed to pay. I know therapists that charged the full session fee if you did not cancel a full week in advance and advised clients that this helped improve their planning skills and underlined the importance of the work.

I have a young child and still manage to make it to my doctor's appts on time. They do not show me grace if I forget. If I cancel, it can be months before the next appt. Surely, they can provide the same level of respect to you. I work with patients suffering from chronic illness with frequent hospitalizations, if they are that sick then they mat not be in a place to see you as they have more pressing concerns. If they aren't, then it is a choice.

If I have someone who no shows or forgets about virtual appts repeatedly, I don't call them until the session is almost over and then offer r/s, (just like I would for an in person no show). I confirmed with administration that this is okay.

 

[texanpsychdoc]

My informed consent outlines that if I haven't heard from them in 3 consecutive weeks from the date of our last session, our professional relationship will be terminated.