assessing client fit in private practice

[Childdoconeday]

Hello,

I am planning to take the leap and am going to begin my private practice within the next 6 mmonths. I am wondering if someone with more severe psychopathology (this is not an area i want to work with in pp) inquires about services, am I able to tell them that i am not a right fit as I specialize in anxiety/do not provide crisis management services / etc etc or do i tell them that I am not accepting pts? My friend and i have differing opinions and she believes its best to say that i am not accepting new clients at this time.

If you are in private practice, how do you handle a situation like this?

Thanks for your thoughts

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[beginner2011]

Hello,

I am planning to take the leap and am going to begin my private practice within the next 6 mmonths. I am wondering if someone with more severe psychopathology (this is not an area i want to work with in pp) inquires about services, am I able to tell them that i am not a right fit as I specialize in anxiety/do not provide crisis management services / etc etc or do i tell them that I am not accepting pts? My friend and i have differing opinions and she believes its best to say that i am not accepting new clients at this time.

If you are in private practice, how do you handle a situation like this?

Thanks for your thoughts

If I'm taking clients then I would not tell someone inquiring about services that I am not taking clients. Personally, I'd view that as unethical (APA Code 5.01). My view is that it's perfectly appropriate to refer someone to another provider if they are seeking a level of care that you do not offer or for a presenting problem/diagnosis for which you do not provide services in your private practice. Not providing crisis management services or treatment for SMI (what does "severe psychopathology" mean?) seem like perfectly appropriate boundaries and grounds for referral, if one does not plan to provide these types of services. Just don't lie about not taking new clients if one is in fact taking new clients.

 

[foreverbull]

I don’t know if I’d go as far as to say it’s unethical to tell folks you’re not taking new clients (remember, these aren’t your clients yet and these aren’t public statements, so that seems like a very stringent interpretation of the code meant to cover public advertising, etc.), but I think it’s better to say you do not feel like a great fit for a client because you cannot provide the level of care that may be needed or that you aren’t competent to treat x issue if it’s out of your competence.

I have turned down some potential clients due to acuity concerns in the past few years and said I thought that they needed a higher level of care or someone who was willing fo provide on-call services, or someone who specialized in X issue. It’s pretty common to do so, especially when it’s a competence or acuity issue. It gets easier to discern with time (I screen for SI/acuity/etc. during my free phone consults).

The trick is just to be tactful with your language about it. I use the “fit” language because it’s true and emphasizes the idea you want them to find the best fit possible rather than emphasizing what you don’t provide.

Occasionally I offer to help the person find referrals in my professional listservs if it’s a rare issue/special population, but not for standard depression, anxiety, etc. If the person gets as far as a phone consult, I might help with referrals a bit if I decide I’m not competent to treat the issue or the acuity is too high, but that situation doesn’t actually come up that often.

 

[WisNeuro]

Yeah, don't lie to people in the professional world, just not a good tact to take. I do think it's unethical, maybe not enough to get t board complaint level , but it's in that realm regardless.

I'd generally agree with others. When I do initial conversations and the diagnostic eval for therapy patients, I always frame the initial session/eval as a consultation session. I am upfront that that initial evaluation is to help flesh out what they are coming in for, as well as determining if seeing me is a good fit, or if we should get them to a provider better suited for the situation. You may be surprised sometimes. They may have a diagnosis in the SPMI range, but perhaps they want to work on a specific issue that fits with your expertise.

 

[Justanothergrad]

Agreed with others. Don't lie, just talk about your fit with their needs. In early conversations, you can also ask specific questions about your emphasis and how it fits with their need then discuss if/when it doesn't.

 

[taylortaylor164]

I will add that I have read this may depend on whether you take insurance or not. From my understanding, insurance companies expect you to take their patients unless your competencies are wildly different than their present problem(s).

 

[MCParent]

I have to turn down a good number of folks, often bc they want telehealth for something not amenable to that or bc they cannot afford my fee. I always offer to put a post on our local provider referral network for them. Ive never had anyone have a bad reaction; I think people get that not all psychs do everything.

 

[PsyDr]

You frame the initial session as a consultation, not an intake. This mitigates the idea that you are abandoning the patient. If you cannot handle the patient, you waive the fee, and tell them diplomatically that you do not perform that service. Do this in the same manner as if they thought you were a psychiatrist or neurologist. Something like, "It seems like you're looking for someone who (insert service). I'm really sorry, but that's not something I do. That happens from time to time. Usually I recommend that people looking for (service) go to (referral). Obviously, I'm not going to charge you for this."

By framing the initial thing as a consultation, and not charging, you are mitigating any accusations that there is a doctor-patient relationship, which is the first prong of a malpractice case. It is not full proof, but it helps. The board cannot force you to do something that you are unqualified to do.

 

[Sanman]

I pretty much agree with what everyone else has mentioned. I would suggest that you prepare a screening form of some sort (in person, phone, website, etc) that helps to screen out and explain to folks that you do not perform those services. I would also have a some local referrals prepped if you do receive those calls and know you will be turning them down.

 

[foreverbull]

You frame the initial session as a consultation, not an intake. This mitigates the idea that you are abandoning the patient. If you cannot handle the patient, you waive the fee, and tell them diplomatically that you do not perform that service. Do this in the same manner as if they thought you were a psychiatrist or neurologist. Something like, "It seems like you're looking for someone who (insert service). I'm really sorry, but that's not something I do. That happens from time to time. Usually I recommend that people looking for (service) go to (referral). Obviously, I'm not going to charge you for this."

By framing the initial thing as a consultation, and not charging, you are mitigating any accusations that there is a doctor-patient relationship, which is the first prong of a malpractice case. It is not full proof, but it helps. The board cannot force you to do something that you are unqualified to do.

That’s what the free phone consultation is for. I give 15-20 free minutes of my time to screen for fit. I personally do not think it is fair to ask psychologists with specialized training to not charge for their first full session, but yes, framing the session as tentative vs. “we will be working together” is important. I even tell folks during the intake after the screening that fit is something we will assess and continue to assess in the first 3-6 sessions or so to leave the door open for referrals if something major comes up and also to make sure the client knows they can decide if our alliance is strong enough to move forward on their side—which empowers them and puts some of their anxieties as ease, I think.

 

[psych.meout]

I don’t know if I’d go as far as to say it’s unethical to tell folks you’re not taking new clients (remember, these aren’t your clients yet and these aren’t public statements, so that seems like a very stringent interpretation of the code meant to cover public advertising, etc.), but I think it’s better to say you do not feel like a great fit for a client because you cannot provide the level of care that may be needed or that you aren’t competent to treat x issue if it’s out of your competence.

No, it's unethical to lie to potential patients to make them go away.

 

[borne_before]

View your private practice as having a velvet rope around it. Maximize the people who are good fits and minimize those who are bad fits. This will allow you do the most good, especially as you practice in your competencies and experience and minimize burn out. I'd probably say "This sounds like a case outside of my competencies. However, I committed to helping you find a psychologist. I would suggest looking here and here. If you need any more help, you could contact your case manager or insurance plan. I wish you the best."

Also, it's important when referring out, for anything, to TALK THEM UP. People judge us by our associations. Who would you rather see and feel better about seeing, "Oh, I guess you could try Dr. Smith???" or "Oh that reminds of colleague, Dr. Smith. Dr. Smith does great work and specializes in some of your challenges. I'd start there. If he is unable to help, he might know someone who can."

 

[Therapist4Chnge]

You frame the initial session as a consultation, not an intake. This mitigates the idea that you are abandoning the patient. If you cannot handle the patient, you waive the fee, and tell them diplomatically that you do not perform that service. Do this in the same manner as if they thought you were a psychiatrist or neurologist. Something like, "It seems like you're looking for someone who (insert service). I'm really sorry, but that's not something I do. That happens from time to time. Usually I recommend that people looking for (service) go to (referral). Obviously, I'm not going to charge you for this."

By framing the initial thing as a consultation, and not charging, you are mitigating any accusations that there is a doctor-patient relationship, which is the first prong of a malpractice case. It is not full proof, but it helps. The board cannot force you to do something that you are unqualified to do.

This is what I would do if I accepted self-referrals. It gets trickier if they are commercial insurance referrals because they typically make you agree to seeing their patients (and quickly!). I require a referral from another provider as another layer to weedout bad cases. When I talk w. the referring provider I am sure to be explicit about my services and what I do and do not offer. I found it helpful to have a clear description about diagnoses seen, services offered, and insurance/payments accepted. I put it on a 1 page fax/email/mailed flyer. I also provided bullet point examples of the most commonly referred cases. I'd rather turn down some biz up front bc it is outside of the patient populations I want to see than take all referrals and get stuck doing work I'd rather not. Borne_before is spot on about the velvet rope idea.

 

[ClinicalABA]

I think you've gotten some good advice above, and you should never practice outside your scope of training and level of competence.

This is a difficult topic. I know that we need to look out for ourselves, but at some level this becomes a public health issue, as these more needy clients A) don't have a place to go (other than crappy, take anybody mid-level-dominated CMHCs); and B) are more likely to come from an historically underserved group. I don't have a good solution (at least not one that wouldn't involve big legislative and systemic changes).