Charging for talking to therapist

[liquidshadow22]

In an insurance based practice do you think it's reasonable/possible to charge for phone calls that are conducted with a patient's therapist at a different location?

I understand that sometimes it's necessary for coordination of care but also many times, patients or therapists request to speak with the psychiatrist by default, even if I have limited concerns about how the treatment is progressing.

It's just very difficult that patients expect you to carve out time in your schedule that may not actually exist to speak to other clinicians.

I understand for child psychiatrists this can be an even greater burden.

Appreciate opinions on this.

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[TexasPhysician]

I don’t charge for this in my practice. I actually encourage it. 2 minutes on the phone with a therapist increases my referrals and pays for itself.

 

[nexus73]

I can see TexasPhysician's point if in private practice. It's just good business.

If I was in an employed job it would probably mean taking time out of documentation time or calling over lunch or end of the day, which I would resent. In which case, scheduling a 45-minute appointment with 10 minutes carved out for therapist call (or some iteration of doing it during the patient's appointment time) would be the least annoying way to do it considering it is not paid.

 

[PsyDr]

You can try to bill for it under 99367, but insurance probably won't pay for it.

 

[calvnandhobbs68]

I can see TexasPhysician's point if in private practice. It's just good business.

If I was in an employed job it would probably mean taking time out of documentation time or calling over lunch or end of the day, which I would resent. In which case, scheduling a 45-minute appointment with 10 minutes carved out for therapist call (or some iteration of doing it during the patient's appointment time) would be the least annoying way to do it considering it is not paid.

If you’re doing it on the date of service, no matter what time of day it is it would still count towards time based billing which would likely knock you automatically into a 99215 when you include the call and documentation time.

Anyway, I don’t really understand the issue here. If the therapist wants to talk to me I tell the patient to have them reach out to my office so we can schedule a time to talk really quick. If I want to talk to the therapist, I make that effort on my end and of course I wouldn’t charge for that.

Is it really that big of a problem that you need to try to nickle and dime patients for 10 minute phone calls with therapists? I can count on one hand the number of times I need to talk to therapists a week and it’s way better time spent than other stuff I do (including writing notes).

 

[liquidshadow22]

If you’re doing it on the date of service, no matter what time of day it is it would still count towards time based billing which would likely knock you automatically into a 99215 when you include the call and documentation time.

Anyway, I don’t really understand the issue here. If the therapist wants to talk to me I tell the patient to have them reach out to my office so we can schedule a time to talk really quick. If I want to talk to the therapist, I make that effort on my end and of course I wouldn’t charge for that.

Is it really that big of a problem that you need to try to nickle and dime patients for 10 minute phone calls with therapists? I can count on one hand the number of times I need to talk to therapists a week and it’s way better time spent than other stuff I do (including writing notes).

Do you run your own practice? I'm in the beginning stages and it is rough. I barely have time to do the basic things I need to do to run the practice. I don't have an office manager yet. I already have no time to fit in patients into my schedule. So I have to have my assistants coordinate booking appointments to talk to therapists into my schedule that is unpaid? Multiple times per week, it adds up.

If there was a way to code for it and make it work that would make it worthwhile.

99215 based on time is what 60 minute visit? I'm sure the reimbursement is crap on an hourly basis but I guess it would be a nice way to at least schedule the followip for an hour and still get some form of reimbursement for the work

 

[splik]

I've never had a therapist want to talk with me. It's usually me or the patient wanting to talk with them. I do charge for calls longer than 30 mins (which almost never happens), but it's poor form to charge for routine brief calls and I don't accept insurance. In an insurance practice, you probably can't charge for brief calls because it is considered a covered service bundled into E&M visits. As mentioned above, for calls >30mins you can bill it as a case conference using 99367 however medicare does not cover this and many commercial insurance won't pay for it either (though some do).

 

[calvnandhobbs68]

Do you run your own practice? I'm in the beginning stages and it is rough. I barely have time to do the basic things I need to do to run the practice. I don't have an office manager yet. I already have no time to fit in patients into my schedule. So I have to have my assistants coordinate booking appointments to talk to therapists into my schedule that is unpaid? Multiple times per week, it adds up.

If there was a way to code for it and make it work that would make it worthwhile.

99215 based on time is what 60 minute visit? I'm sure the reimbursement is crap on an hourly basis but I guess it would be a nice way to at least schedule the followip for an hour and still get some form of reimbursement for the work

Sounds like you have some work to do here in both education and time management.

99215 is 40+ minutes for a followup. You should work on familiarizing yourself with billing codes ASAP to maximize your own reimbursement for the work you do.

Anyway I’m not understanding your issue here. If therapists want to talk to me, I tell the patient to tell the therapist to give our office a call so my admin assistant can give them my personal email or phone number and we can coordinate a time to talk. If I want to talk to a therapist, I just do the same thing from my end. All therapists I’ve talked to have my cell number or my email. Nobody is “scheduling” time into patient blocks, we just text or email and figure out a time to call during lunch or right after work.

I mean if your mentality is that you literally do no other work outside of scheduled patient visits then okay I guess I could see how this is so distressing for you. I’m not a martyr but I do get that I might need to talk to random therapists to coordinate about a patient for 10-15min couple times a week during my lunch hour or at 5PM.

 

[PikminOC]

I don’t charge for this in my practice. I actually encourage it. 2 minutes on the phone with a therapist increases my referrals and pays for itself.

None of them talk for only two minutes. And it takes a while to set up the meetings too.

 

[FlowRate]

In my employed setup, I have 2hr admin time per day to take care of anything that's not direct patient care. Regardless of who wants to talk with whom, it usually works out that I call their number, leave a voicemail with my typical admin times, and invite them to text my work cell if they'd like to arrange a specific time from those options or different time than what I offered. It's been a reasonably productive endeavor about 60-75% of the time. Even the 25% at least allows me to identify that their therapist is not particularly impressive with regard to formulation of the case and/or chosen modality. I probably end up only having to arrange this sort of things a few times a month at most.

 

[smalltownpsych]

My patients talk to the psychiatrists themselves and I help them through it. Many of my patients have communication difficulties and addressing those is part of the treatment. They tend to have less issues talking to their psychiatrist than other people in their lives. NPs want to talk to me all the time, but I find that it is waste of my time and I told my office admin that if a psychiatrist wants to talk, go ahead and schedule a time, but if it’s an NP, check with me first. in other words, I am more accessible for activities that are more likely to be productiv and I use similar strategies with patients.

 

[FlowRate]

My patients talk to the psychiatrists themselves and I help them through it. Many of my patients have communication difficulties and addressing those is part of the treatment. They tend to have less issues talking to their psychiatrist than other people in their lives. NPs want to talk to me all the time, but I find that it is waste of my time and I told my office admin that if a psychiatrist wants to talk, go ahead and schedule a time, but if it’s an NP, check with me first. in other words, I am more accessible for activities that are more likely to be productiv and I use similar strategies with patients.

I have a similar experience with (doctoral level) psychologists vs LCSWs vs other (LPC, LAC, LMFT although I'm aware that can be a doctoral program). I'll usually put in more effort to talk to a patient's therapist if they're a psychologist. I recently made the mistake of asking a patient for permission and contact info for their therapist--who they kept calling their psychologist--before verifying that the therapist was actually a psychologist, only to find out they were an LPC who exclusively practices "somatic psychotherapy" and had never heard of ERP when I brought it up given the patient was struggling with OCD...

 

[TexasPhysician]

Do you run your own practice? I'm in the beginning stages and it is rough. I barely have time to do the basic things I need to do to run the practice. I don't have an office manager yet. I already have no time to fit in patients into my schedule. So I have to have my assistants coordinate booking appointments to talk to therapists into my schedule that is unpaid? Multiple times per week, it adds up.

If there was a way to code for it and make it work that would make it worthwhile.

99215 based on time is what 60 minute visit? I'm sure the reimbursement is crap on an hourly basis but I guess it would be a nice way to at least schedule the followip for an hour and still get some form of reimbursement for the work

I’m a bit confused on how you are in the beginning stages of pp, but you have no time to fit in current patients.

If you have an abundance of patients and referrals, direct your staff to tell the therapist to fax their clinical concerns and their cell number. You can call with follow-up questions. 95% of therapist calls have no clinical usefulness. They probably won’t be pleased, but you are full so it doesn’t matter.

If you are still building a private practice, make the time and give them your cell number to call with emergencies. They’ll appreciate it, and you get patients at an advertising acquisition cost of $0.

 

[Candidate2017]

None of them talk for only two minutes. And it takes a while to set up the meetings too.

I once had a therapist ask to speak weekly.

95% of therapist calls have no clinical usefulness.

Most adults are capable of relaying info. So, patient requests to call the "therapist" are usually attempts to split or triangulate against the psychotropic plan.

Sometimes, the therapist wants me to call and justify why I'm not prescribing a stimulant or other med they've recommended to the patient. Other times, the therapist wants to talk because the patient complained I'm mean (i.e., not prescribing their controlled sub of choice). These calls reveal more about the "therapists'" lack of training/competence than any clinical info. Nowadays, I have staff call the therapist and ask what message they wish to relay, and then have staff call back with a short reply. This cuts down on having to provide therapy supervision, as well as reducing my urge to ask the therapist if they are a licensed physician duly qualified to write scripts.

If anything needs to be actually communicated, it's more efficient to have the patient send their notes. Anyway, the old school docs were wise on insisting upon no split treatment, that all therapy needs to be done with them. But in the world of third-party payor, volume is king.

 

[PikminOC]

I’m a bit confused on how you are in the beginning stages of pp, but you have no time to fit in current patients.

If you have an abundance of patients and referrals, direct your staff to tell the therapist to fax their clinical concerns and their cell number. You can call with follow-up questions. 95% of therapist calls have no clinical usefulness. They probably won’t be pleased, but you are full so it doesn’t matter.

If you are still building a private practice, make the time and give them your cell number to call with emergencies. They’ll appreciate it, and you get patients at an advertising acquisition cost of $0.

You take insurance right? Doesn't that mean they shovel in the patients for you?

 

[PikminOC]

In my employed setup, I have 2hr admin time per day to take care of anything that's not direct patient care. Regardless of who wants to talk with whom, it usually works out that I call their number, leave a voicemail with my typical admin times, and invite them to text my work cell if they'd like to arrange a specific time from those options or different time than what I offered. It's been a reasonably productive endeavor about 60-75% of the time. Even the 25% at least allows me to identify that their therapist is not particularly impressive with regard to formulation of the case and/or chosen modality. I probably end up only having to arrange this sort of things a few times a month at most.

Seems like a huge waste of productive rvu time

 

[tr]

I once had a therapist ask to speak weekly.



Most adults are capable of relaying info. So, patient requests to call the "therapist" are usually attempts to split or triangulate against the psychotropic plan.

Sometimes, the therapist wants me to call and justify why I'm not prescribing a stimulant or other med they've recommended to the patient. Other times, the therapist wants to talk because the patient complained I'm mean (i.e., not prescribing their controlled sub of choice). These calls reveal more about the "therapists'" lack of training/competence than any clinical info. Nowadays, I have staff call the therapist and ask what message they wish to relay, and then have staff call back with a short reply. This cuts down on having to provide therapy supervision, as well as reducing my urge to ask the therapist if they are a licensed physician duly qualified to write scripts.

If anything needs to be actually communicated, it's more efficient to have the patient send their notes. Anyway, the old school docs were wise on insisting upon no split treatment, that all therapy needs to be done with them. But in the world of third-party payor, volume is king.

In some cases, treatment coordination with the therapist is critical. I'm thinking specifically of cases where the patient is doing graded exposure therapy for anxiety or PTSD, or CBTi for insomnia, with a separate therapist, and I am concurrently treating them with antianxiety agents or sleepers. In those cases I usually try to check with the therapist about any schedule of dosage changes, because the patient needs to be symptomatic enough to have material to work on in therapy, but then be able to pull back slowly on the medication as they progressively gain cognitive/behavioral mastery over their symptoms. These calls don't usually take too long and I'm happy to do them.

I'm less enthused about therapists who want to call me to "touch base," and then spend inordinate amounts of time regaling me with detailed recountings of various aspects of the patient's personal life, which may certainly have bearing on whatever they are doing in therapy but honestly don't really affect my decisions about their medication at all. I admit to trying to avoid these types of interactions. I'm not sure why the therapists don't also find it burdensome to waste their time with these long phone calls that contribute nothing to quality of care.

I can't recall ever having a therapist call to ask me to justify why/why not a certain choice of medication. At most I occasionally hear from patients that their therapist suggested a particular medication. I don't have a problem with that. The treatment decision is still going to be based on a conversation between me and the patient.

 

[TheRightMedication]

I am still early-ish in my career so talking to therapists is networking for me. I can get a sense of how good they are over the phone, as I need to build my list of therapists to refer to.

In my experience there is a large number of therapists who also are interested in feeling out psychiatrists, so our conversation can lead to referrals.

I've never had a therapist give me a bunch of random historical tidbits about a case, as above posts have said. If that happened I would strike them off the good list, and wouldn't talk to them again.

 

[randomdoc1]

I once had a therapist ask to speak weekly.



Most adults are capable of relaying info. So, patient requests to call the "therapist" are usually attempts to split or triangulate against the psychotropic plan.

Sometimes, the therapist wants me to call and justify why I'm not prescribing a stimulant or other med they've recommended to the patient. Other times, the therapist wants to talk because the patient complained I'm mean (i.e., not prescribing their controlled sub of choice). These calls reveal more about the "therapists'" lack of training/competence than any clinical info. Nowadays, I have staff call the therapist and ask what message they wish to relay, and then have staff call back with a short reply. This cuts down on having to provide therapy supervision, as well as reducing my urge to ask the therapist if they are a licensed physician duly qualified to write scripts.

If anything needs to be actually communicated, it's more efficient to have the patient send their notes. Anyway, the old school docs were wise on insisting upon no split treatment, that all therapy needs to be done with them. But in the world of third-party payor, volume is king.

yes, there are so many "therapists" out there who do more harm than good. In some respects, I don't blame insurances for auditing their a$$es (chances are their documentation is sh_t and they don't deserve to get paid). I've had similar experiences and they obviously have no training whatsoever in pharmacology and those who try to walk in to that territory are often greatly lacking in basic competencies they should be having in their role. It includes poor diagnostic ability, poor therapy technique, and lack of self awareness of their own countertransference. Good grief, thinking of a case right now of a patient with borderline personality who does THC and heavy etoh daily. Therapist kept trying to get a hold of me arguing why I don't just put her on Adderall and Xanax. I eventually discharged this patient. She found an NP, escalated her Adderall dose in no time, graduated to IR and bam, multiple state database flags. Can't say I'm surprised.

One benefit of talking to therapists as others alluded to is feeling out other providers. They feel you out too. I network with good providers. You refer to each other and make a good pipeline of referrals for each other and better patient outcomes.

 

[liquidshadow22]

I’m a bit confused on how you are in the beginning stages of pp, but you have no time to fit in current patients.

If you have an abundance of patients and referrals, direct your staff to tell the therapist to fax their clinical concerns and their cell number. You can call with follow-up questions. 95% of therapist calls have no clinical usefulness. They probably won’t be pleased, but you are full so it doesn’t matter.

If you are still building a private practice, make the time and give them your cell number to call with emergencies. They’ll appreciate it, and you get patients at an advertising acquisition cost of $0.

Closing in on 3rd year but still have another employed job so my 2.5 days of clinic time is booked solid now. I still want to grow the practice however. I am at the critical point where I need to reduce the employed position because it has become untenable.

I think just extending appt time to 45 minute followup and billing 99215 might make the most sense to at least capture some reimbursement for the work

 

[allantois]

Therapists recommending meds to patients is the bane of my existence. Another one is them recommending they get an autism eval.. I've also seen some of their notes say unpleasant things about myself or even their opinions on patient's medications. I should start putting notes on what I think about their EMDR approaches to everything and anything not remotely related to trauma..

 

[tr]

I've never had a therapist give me a bunch of random historical tidbits about a case, as above posts have said. If that happened I would strike them off the good list, and wouldn't talk to them again.

Really? I feel like this is the majority of the interactions I have with psychotherapists.
It really flummoxes me because don't they value their professional time?

I feel like when I talk to another physician, the conversation is always extremely to the point. There's a relatively rapid exchange of all the critical information in a dense, informative way, and as soon as that's done and we are mutually agreed on a plan, we hang up. We are both in total recognition and agreement that we all have busy lives and nobody wants to kill their time on the phone jawing about unnecessary details that don't affect the plan.

Many therapists really don't seem to function this way. A lot of them seem like they are perfectly happy to spend lots of time just chewing over their case formulation with me on the phone. Sometimes they seem kind of frustrated by the fact that I don't really volley with them. It's like they have some social expectation that I should reciprocate what they are doing with my own irrelevant anecdotes about the patient's personality, experiences, decisions, or whatever.

Don't they charge by the hour too?

 

[PikminOC]

Many of them push stims because their patients are obviously suffering from ADHD per their opinion.

 

[psychma]

I was trained to speak with the prescribing physician under limited circumstances. I do not do EMDR, wax poetic about the client or desire to waste my time or yours. I do not suggest medications. Not my wheelhouse. I have spoken on two occasions to diff psychiatrists with ROI. The exchanges were friendly but professional. I think they took 5 minutes.

I don’t generally have much need to speak with my patient’s psychiatrists and can’t imagine what they would get from speaking to me except in these two rare cases.

 

[smalltownpsych]

Really? I feel like this is the majority of the interactions I have with psychotherapists.
It really flummoxes me because don't they value their professional time?

I feel like when I talk to another physician, the conversation is always extremely to the point. There's a relatively rapid exchange of all the critical information in a dense, informative way, and as soon as that's done and we are mutually agreed on a plan, we hang up. We are both in total recognition and agreement that we all have busy lives and nobody wants to kill their time on the phone jawing about unnecessary details that don't affect the plan.

Many therapists really don't seem to function this way. A lot of them seem like they are perfectly happy to spend lots of time just chewing over their case formulation with me on the phone. Sometimes they seem kind of frustrated by the fact that I don't really volley with them. It's like they have some social expectation that I should reciprocate what they are doing with my own irrelevant anecdotes about the patient's personality, experiences, decisions, or whatever.

Don't they charge by the hour too?

Even as psychologists we are guilty of this particular dynamic. We just don’t get a lot of practice giving the succint details that are clearly relevant the way that MDs do. I have worked extensively in a medical setting and have always tended to want to quickly get to the point and I still am not as good at it as the average physician. Because time is money, I continue to work on it.

 

[tr]

Even as psychologists we are guilty of this particular dynamic. We just don’t get a lot of practice giving the succint details that are clearly relevant the way that MDs do. I have worked extensively in a medical setting and have always tended to want to quickly get to the point and I still am not as good at it as the average physician. Because time is money, I continue to work on it.

That's a very good point. I guess I was imagining that there was just a lack of motivation to be succinct on the part of the therapists.

But it's true that medical training really very forcefully and explicitly inculcates the ability to present a great deal of clinical detail in a concise yet complete and informative way. The threat of public humiliation is a powerful motivator.

Psychology training must be very different. On occasions when I get in a room with a group of psychologists I often feel like we are almost speaking different languages. A lot of what they say goes over my head.

 

[WisNeuro]

That's a very good point. I guess I was imagining that there was just a lack of motivation to be succinct on the part of the therapists.

But it's true that medical training really very forcefully and explicitly inculcates the ability to present a great deal of clinical detail in a concise yet complete and informative way. The threat of public humiliation is a powerful motivator.

Psychology training must be very different. On occasions when I get in a room with a group of psychologists I often feel like we are almost speaking different languages. A lot of what they say goes over my head.

Varies quite a bit. I'd say neuropsychs are probably more on the succinct side of things. Many of us are used to having to give a comprehensive, yet fairly brief summary of things in settings like multidisciplinary neurosurg meetings (e.g., epilepsy, tumor, etc) and other settings. I'd also wager there may be a difference between primary therapeutic orientations and long-windedness.

 

[clozareal]

I charge for all collateral calls to the therapist/school by the minute. Unreimbursed for the most part, which is what it says on my intake forms. It's a service and time that I am providing for them outside of their appointment time. Why wouldn't I charge for it? I don't like that insurance dictates what should be considered appropriate or not for physicians and then reimburse based on it.

I don't agree that it's poor form to charge for routine brief calls. I've had now half a dozen patients offer to pay me for the time of my free phone screen, even when they know it's free ahead of time! If it's a medical question that requires my training/expertise, then I will charge for it. If it's a scheduling issue, they can do that themselves on my patient portal without my input so no time spent on my part unless it's a last minute cancellation, which I will charge for. If it's a prescription refill, then I don't charge for that but they can request that to their pharmacy or use my patient portal.

It's important to find ways for me to optimize my time and get paid for my work. Some people charge a high rate because they incorporate all these extra little things into it, but that would require you to also limit your clinical hours to have admin time and actually do it. I find it much more reinforcing/motivating for me to get things done when I know I'm getting paid for it.

 

[clausewitz2]

I charge for all collateral calls to the therapist/school by the minute. Unreimbursed for the most part, which is what it says on my intake forms. It's a service and time that I am providing for them outside of their appointment time. Why wouldn't I charge for it? I don't like that insurance dictates what should be considered appropriate or not for physicians and then reimburse based on it.

I don't agree that it's poor form to charge for routine brief calls. I've had now half a dozen patients offer to pay me for the time of my free phone screen, even when they know it's free ahead of time! If it's a medical question that requires my training/expertise, then I will charge for it. If it's a scheduling issue, they can do that themselves on my patient portal without my input so no time spent on my part unless it's a last minute cancellation, which I will charge for. If it's a prescription refill, then I don't charge for that but they can request that to their pharmacy or use my patient portal.

It's important to find ways for me to optimize my time and get paid for my work. Some people charge a high rate because they incorporate all these extra little things into it, but that would require you to also limit your clinical hours to have admin time and actually do it. I find it much more reinforcing/motivating for me to get things done when I know I'm getting paid for it.

My professional life did get about 10000% less obnoxious once I started charging a prorated document preparation fee.

 

[R. Matey]

Psychology training must be very different. On occasions when I get in a room with a group of psychologists I often feel like we are almost speaking different languages. A lot of what they say goes over my head.

I've had this experience too with psychiatry residents/fellows, mostly when discussing psychological testing and theoretical case conceptualizations. That said, I killed on my CBT case-cons when I went up for comps in grad school only to be very publicly schooled on the finer points of cognitive therapy by a psychiatrist while I was on internship.

 

[MedMan80]

My favorite is a former therapist in my hosp practice that kept wanting me to put young kids on mood stabilizers, and when I would retort sarcastically "which mood stabilizer", she'd retort back, "i don't know, you're the doctor".

 

[smalltownpsych]

I’m laughing at the concept of therapists pushing stimulant meds onto patients as it doesn’t sound like the psychiatrists wants to pay attention to them either. Just because the patient can’t follow their long winded rambling dialogue doesn’t mean they have attention problems. lol.

Seriously though, sometimes that rambling style along with throwing out initials like EMDR is a cover for not knowing what they are doing and the more likely that is to be noticed, then the worse it tends to get.

 

[clausewitz2]

I’m laughing at the concept of therapists pushing stimulant meds onto patients as it doesn’t sound like the psychiatrists wants to pay attention to them either. Just because the patient can’t follow their long winded rambling dialogue doesn’t mean they have attention problems. lol.

Seriously though, sometimes that rambling style along with throwing out initials like EMDR is a cover for not knowing what they are doing and the more likely that is to be noticed, then the worse it tends to get.

I do kind of want to do up a midlevel buzzword bingo card. EMDR has pride of place, of course, but mentions of the vagus nerve outside of literal descriptions of anatomy is definitely on there too.

 

[psychma]

Not every therapist embraces EMDR or vasovagal theory. Many of us have a brain in our heads and aren’t afraid to speak up. This is akin to the psychiatrist who wants to waste time, money, and years training in psychoanalytic theory. Can that go on the bingo card?

 

[comp1]

People's responses to this are confusing. Care coordination with other providers is literally a core part of the billing codes used. You don't bill something extra for it. It's like billing extra for getting a blood pressure. I understand it's not enjoyable and I even get that it's rarely useful. I personally hate it, but it's already accounted for in the billing codes. I can tell you that working within a single system where you can direct message the therapist instead of trying to schedule appointments to chat makes it a million times better and is something people should consider when looking for jobs. Obviously you can charge how you want in a cash practice, but in an insurance based practice, care coordination is already covered by the usual EM codes.

 

[PikminOC]

Many of them push stims because their patients are obviously suffering from ADHD per their opinion.

I just had an lcsw write me that she is highly educated and knows she has ADHD and bipolar. She demands I see her online as she is so busy and knows her diagnoses already.

 

[smalltownpsych]

I just had an lcsw write me that she is highly educated and knows she has ADHD and bipolar. She demands I see her online as she is so busy and knows her diagnoses already.

Makes one wonder how she can help patients navigate boundaries when she doesn’t respect or even see the point of others having them.