How to manage when you have too many clients?

[Groupthink]

Hitting a dead end here and I don't know what to do about it. I was called into my director's office today. She told me she is concerned about my caseload and wants me to reduce the number of clients I see each day.

I am seeing an average of 30 people per week, each on a 6 to 12 session treatment plan. I schedule back to back, most days having 7 clients in a row with a lunch break in between or time scheduled for meetings on days when I see 5 or 6 clients.

The director recently upped our number of intakes, so I am receiving at least 4 new people per week depending on if I absorb crisis walk-ins. I am scheduling people 3 weeks out for appointments. My clients are pissed if they miss a session because they can't reschedule for almost a month.

I am absolutely feeling the burn(out). I get home at 6 and I go to sleep because I am so exhausted, just to do it all again the next day.

My issue is that none of the other staff are experiencing this. Yes, they have 7 clients days but undoubtedly they have no shows or cancellations. I asked my director, and she indicated that I have the lowest cancellation rate out of all our staff.

I asked if I could have my number of new clients reduced, but this request was denied because it would be unfair to the other staff and because we need to meet client demand. I explained my predicament and the response I received was, "It's the curse of being a competent therapist. Your patients like you, and you are quite effective at what you do."

Am I just supposed to suck it up and tell people I can't see them again for another month? Is this what life as a full-time therapist is supposed to be? I know for a fact this is affecting my mental health.

Work has become more difficult than anything I ever did in graduate school. I've found myself browsing how to get certifications in other things, simply because I am so tired from this work. I know that this is temporary, as we undoubtedly cut our caseload when the summer break rolls around, but these are signs of burnout and possibly depression and it's becoming a real concern for me. I am not sure what to do.

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[Therapist4Chnge]

That is a tough position to be in.

Can you adjust your treatment plans to be more targeted (i.e. have less goals) and reduce the overall # of sessions needed? How about adjusting frequency?

 

[Groupthink]

Absolutely; this has been my guiding principle since I noticed my caseload inflating. I have been trending towards 6 sessions and I am hesitant to reduce less than that unless substantial progress is made quite quickly. Frequency has been my other change, having moved a handful of people to monthly appointments, but most people protest when I introduce this. I offer to refer them to outside services since I cannot meet their needs, but they decline. Letting them down like that is frustrating, I wish I did not have to do that.

I've been working here for 4 years now and it's never been like that before. Granted, I was a trainee during my first year but it's like the demand has increased beyond anything I ever expected.

 

[Justanothergrad]

That's a draining position but there is some positive. That the director wants you to reduce your client load is an administratively supportive position and one that you should take them up on. That may mean scheduling people out and reducing overall sessions as well. If clients are upset because they can't get in to see you for a month, that is unfortunate and that's the downside to missing appointments. Don't make that frustration something you need to hold onto. Sadly, we are not a business that is going away and so there is always going to be a need for your services.

 

[PsyDr]

1) DO NOT go to sleep at 6pm when you’re burnt out.

2) sometimes going on vacation causes other people to readjust their expectations.

3) if you can, raise your rates until your caseload gets manageable.

4) you can ALWAYS refuse to see someone and it is ethical to decline to treat someone whom you cannot treat effectively. Asking an administrator in writing if they are willing to compromise patient safety because they have their own agenda or if they will allow you to have fewer patients might be an interesting email to create.

 

[Groupthink]

Justanothergrad, I appreciate your comment about my director. I agree, she has been understanding and I believe recognizes my challenges while doing double duty to both her staff and to our clients. It is why I wanted to work at this position, and up until recently felt energized about being here.

1) DO NOT go to sleep at 6pm when you’re burnt out.

2) sometimes going on vacation causes other people to readjust their expectations.

3) if you can, raise your rates until your caseload gets manageable.

4) you can ALWAYS refuse to see someone and it is ethical to decline to treat someone whom you cannot treat effectively. Asking an administrator in writing if they are willing to compromise patient safety because they have their own agenda or if they will allow you to have fewer patients might be an interesting email to create.

I am curious why I should not go to sleep at 6. I am physically drained and tired all of the time and doctors can't figure out why. It never used to be this way. I try to work out 4x/week but recently I am too tired after work.

Regarding 2 and 3: I am not allowed to take off more than 2 days during the semester due to client load, and rates are set by the university who govern our medical center's finances. There is no flexibility in charging more.

Regarding number 4, we have a strict referral policy for SPMI and cases that present with high-risk. We have case management meetings regarding referral of intakes for the very purpose of providing the best services for our clients. It is not in the best interest of clients with SPMI to be treated here given the level of need and our lack of resources.

It is tough because a lot of the I/O Psych literature shows how increased responsibility is correlated with increased job satisfaction. While I don't have responsibility over a lot of the policy in this workplace, I have a metric ton of responsibility in terms of client load and case management. It really feels like too much sometimes.

 

[bcliff]

Have you scoped out/applied for any other positions in your area?


Sent from my iPhone using SDN mobile

 

[erg923]

I am curious why I should not go to sleep at 6.

Behavioral activation for mood.

 

[Fan_of_Meehl]

Hitting a dead end here and I don't know what to do about it. I was called into my director's office today. She told me she is concerned about my caseload and wants me to reduce the number of clients I see each day.

I am seeing an average of 30 people per week, each on a 6 to 12 session treatment plan. I schedule back to back, most days having 7 clients in a row with a lunch break in between or time scheduled for meetings on days when I see 5 or 6 clients.

The director recently upped our number of intakes, so I am receiving at least 4 new people per week depending on if I absorb crisis walk-ins. I am scheduling people 3 weeks out for appointments. My clients are pissed if they miss a session because they can't reschedule for almost a month.

I am absolutely feeling the burn(out). I get home at 6 and I go to sleep because I am so exhausted, just to do it all again the next day.

My issue is that none of the other staff are experiencing this. Yes, they have 7 clients days but undoubtedly they have no shows or cancellations. I asked my director, and she indicated that I have the lowest cancellation rate out of all our staff.

I asked if I could have my number of new clients reduced, but this request was denied because it would be unfair to the other staff and because we need to meet client demand. I explained my predicament and the response I received was, "It's the curse of being a competent therapist. Your patients like you, and you are quite effective at what you do."

Am I just supposed to suck it up and tell people I can't see them again for another month? Is this what life as a full-time therapist is supposed to be? I know for a fact this is affecting my mental health.

Work has become more difficult than anything I ever did in graduate school. I've found myself browsing how to get certifications in other things, simply because I am so tired from this work. I know that this is temporary, as we undoubtedly cut our caseload when the summer break rolls around, but these are signs of burnout and possibly depression and it's becoming a real concern for me. I am not sure what to do.

How much response-contingent positive reinforcement you getting these days?

It seems like a lot of therapy can be punishing and exhausting.

 

[G Costanza]

Edit: Misread the OPs setting.

 

[student til 30]

Is the organization thinking about hiring more staff to meet the increased demand, or referring out? I'm all for providers working a bit harder to meet increased demand, and engaging in good practice management, but at some point it's on the organization. Individual providers aren't responsible for making sure everyone in a healthcare system gets seen, and administrators shouldn't shift undue responsibility to them. Cutting vacation time to meet increased demand just seems counterproductive.

If you're getting burned out with a regular full-time case load, check in with yourself and your practice. The larger your caseload gets, the more I'd attribute burnout to situational factors.

 

[medium rare]

Therapy is not necessarily stressful but it can be extremely draining. Coming home and going directly to bed can leave you feeling more exhausted over time.

In situations like this, I have found it imperative to set firm boundaries regarding your limitations/capabilities. You cannot provide quality services if you are burned out.

 

[PsyDr]

Justanothergrad, I appreciate your comment about my director. I agree, she has been understanding and I believe recognizes my challenges while doing double duty to both her staff and to our clients. It is why I wanted to work at this position, and up until recently felt energized about being here.



I am curious why I should not go to sleep at 6. I am physically drained and tired all of the time and doctors can't figure out why. It never used to be this way. I try to work out 4x/week but recently I am too tired after work.

Regarding 2 and 3: I am not allowed to take off more than 2 days during the semester due to client load, and rates are set by the university who govern our medical center's finances. There is no flexibility in charging more.

Regarding number 4, we have a strict referral policy for SPMI and cases that present with high-risk. We have case management meetings regarding referral of intakes for the very purpose of providing the best services for our clients. It is not in the best interest of clients with SPMI to be treated here given the level of need and our lack of resources.

It is tough because a lot of the I/O Psych literature shows how increased responsibility is correlated with increased job satisfaction. While I don't have responsibility over a lot of the policy in this workplace, I have a metric ton of responsibility in terms of client load and case management. It really feels like too much sometimes.

I might not be an expert on treating burn out, but I am surely an expert on being burnt out.

1) Going to bed super early is a GREAT way to:

a) become physically deconditioned, so everything seems harder during the day, making you more tired, until you're wanting to sleep at 5pm, 4pm, etc.
b) take up a huge portion of time, so you can't have fun/general positive reinforcement of life. Pretty soon, you'd complain that nothing is fun, and you'd be right because you're not having fun.


2) There is ZERO chance your employment contract actually says that. Employment laws have some stipulations about such things. Depending on how you wanna play it, you'd be within your rights to tell them you're gonna take your vacation days or contact your state's labor board.

3) Fine.

4) You're missing my point. Professional ethics and most state laws say it is your duty to not see patients when you'd be ineffective. You can assert that at your current case load, you are not effective. If you put this in writing, and ask your employer if they would like to give you the same case load as everyone else where you can effectively treat others, or would they prefer you engage in malpractice. They will be mad, but screw them.

 

[Justanothergrad]

2) There is ZERO chance your employment contract actually says that. Employment laws have some stipulations about such things. Depending on how you wanna play it, you'd be within your rights to tell them you're gonna take your vacation days or contact your state's labor board.

I've seen numerous places talk about things that would never be enforceable, but they just rely on people believing them. Heck, I've even seen stuff in employment contracts that would never hold up. I saw one place (a small practice with a number of employees that could be counted on one hand) who had folks sign a no compete for 5 years that stipulated that those who left the company could not any provide mental health services within a 5 county area because that was the catchment area from which clients were drawn. It would never hold up because its way to broad (geograpically, timewise, and service wise), but people put stupid stuff in writing. Still though, it'd be interesting to watch them wiggle when they have to explain in writing why you can't take vacations during the semester (even if it isn't in the contract).

 

[Groupthink]

Just want to thank everyone for the supportive posts!

erg: It goes to show you that I am clearly not applying the principles of my work I use daily to my own life. It's obvious now that not oversleeping is a form of BA. My thinking is cloudy, and if I can't realize something so simple about my own life then I do wonder if I am not at my best for my clients.

student til 30: That is an issue. We are down 4 staff members and have hit some road bumps in trying to hire more. All the while our outreach and marketing programming has doubled due to a grant we received last year. We are all feeling the effects of it, but the only response we've received from the head of the medical center is "It won't be an issue once your department has more staff". Most of my colleagues state, "Well, another staff member will only be able to take on a case load of ~80 clients, and demand is so high it will just fill up quickly. More staff isn't the answer." I do not agree with the latter position, but it is the common sentiment. IMO, anything to take the edge off.

PSYDR: My contract states I am expected to work 50 hours a week or "until the job is done". This language is why I am expected to provide programming after hours occasionally, and it has been quoted as why we are not allowed to take off extended vacation during the semester due to client demand (therefore the job is not done until the semester is over). It feels like a stretch, I know. Thankfully my work has never denied a request for a day off, but it's difficult to take days off. I like 3 day weekends, but if I am booking 3 weeks out I don't want to cancel when I am seeing 7 people on a Friday and make them all wait another 3 weeks. That means I need to plan my 3 day weekends a month ahead of time, but even just planning that throws off the 3 week rhythm I have for my treatment plans and ugh...

 

[Ollie123]

Second what everyone has said about not getting sucked into the "Too exhausted to do anything but sleep all the time" cycle. Been there, done that. Meet a friend for dinner, go see a movie, DO NOT go home and give yourself the opportunity to crash or the cycle will perpetuate.

It sounds like you are in a UCC. For who knows what reason, it seems like these places have twice the "I must throw myself on the sword for my patients" attitude than anyplace else or then is possibly justified by circumstances. I saw it when prac'ing at one, I have two friends who interned at them and saw it and one friend working at one now who is going through the same thing. I have no idea where this comes from, if its a way to reduce cognitive dissonance from the typically miserable salaries or if it is a way to pushback against the old stereotype that counseling/counseling centers are for treating "procrastination" and not mental illness. Newsflash: Yes, college students have mental illness but no, the level of acuity is not such that a staff member going on vacation is going to cause a mass suicide. For crying out loud, SMI is referred OUT and even the folks I know treating that population can take a frikkin vacation.

7 patients a day is draining, but not outrageously unreasonable depending on population. I do agree it would be monotonous after a while, especially if that is 5x/week. Have you done it before? I'm wondering if there is more to it than just the volume. It sounds like its not really the workload per se, but moreso guilt about the suboptimal care that the setting necessitates.

1) Draw boundaries.
2) Have frank conversations (see below)
3) Look for other jobs

They sound like they are in a situation where it would be disastrous for them to lose even more staff. This gives you power. They are saying to reduce your caseload, which is actually great. Unless I missed something, it sounds like they aren't telling you how. Put it back on them to tell you how. If you think it is suboptimal care - I wouldn't shy away from doing exactly what psydr said and asking them plainly how you should reduce the quality of your care. And I'm generally a pretty passive person. Did they say they want you to schedule people less frequently? Do they have someone you should refer some of your patients to? Make that clear. Get it in writing if need be. But the onus is on them to tell you how if they aren't letting you reduce your intakes. Which by the way...is strange. I'm guessing these are not full 8-hour assessment batteries. I can crank out an intake report in 15-20 minutes now so its not an overly burdensome amount of paperwork. Maybe yours are longer, but still - I don't find intakes any more/less draining than other potential activities. Why is it so important that these be equal across staff when clearly therapy caseloads are not.

I'm not sure what is keeping you there, but I'd be putting some feelers out there in other settings. It doesn't sound like it would be hard to find something better than what you have. If you want to stay and want to step up, start talking with them about ways to change the workflow. Have a dedicated intake person who ONLY does intakes? Change the scope and start referring more people out? Push hard to change the system or get out if its not one you feel is workable for you.

 

[PsyDr]

PSYDR: My contract states I am expected to work 50 hours a week or "until the job is done". This language is why I am expected to provide programming after hours occasionally, and it has been quoted as why we are not allowed to take off extended vacation during the semester due to client demand (therefore the job is not done until the semester is over). It feels like a stretch, I know. Thankfully my work has never denied a request for a day off, but it's difficult to take days off. I like 3 day weekends, but if I am booking 3 weeks out I don't want to cancel when I am seeing 7 people on a Friday and make them all wait another 3 weeks. That means I need to plan my 3 day weekends a month ahead of time, but even just planning that throws off the 3 week rhythm I have for my treatment plans and ugh...

Yeah, unless your work has never changed, that's what we would call an unenforceable clause. But it really sounds like they are pressuring you, and you are being agreeable and not fighting it. I would HIGHLY recommend some assertiveness training here. You're not stupid, so it's not like your falling for some line. It sounds like they are banking on you not being assertive, and working you to the bone for their benefit.

 

[foreverbull]

What you described is why I left UCCs/college counseling and decided not to do it full time. Demand for services and acuity have both increased every year in settings I've worked at, meanwhile funding has not, so staff are overworked. Students are generally limited to 8 to 10 sessions and then pushed out to community services, and many of them clearly needed long-term care, so I felt like I was putting a Band-Aid on a gaping wound sometimes. I saw where it was headed and got out.

Feel free to bargain with your employer since you've worked there for a while and have negotiating power. But perhaps there are other options or better UCCs, and it might behoove you to test that out. You may find that counseling centers arent for you in the long run, or you may like a change in employers, specifically.

I had every intention of being a staff psychologist at a UCC for life until internship year, when I saw how overworked the staff were and how much crisis and high acuity everyone was seeing, and the demand increased by 15%+ at my site that year. Several colleagues at college sites in different states were experiencing the same thing and got out. A few stayed, but not as many as had initially planned to.

You may want to spend some time reflecting on whether this is something you want to do long term, particularly if you imagine having a few less clients here and there. Would that be enough to help you feel better about what you do every day?

 

[G Costanza]

Still at a UCC and the trend is to stop referring SPMI out. I’m doing safety plans with probably 1/2 of my new clients. We are hospitalizing someone most days of the week lately. I’m working with people who have schizophrenia, delusional disorder, etc. If you come in with GAD, I’m scheduling you one month out because that’s low level acuity at this point.

The age of UCCs being anything other than community mental health are coming to an end.

 

[hamstergang]

I'm a psychiatrists, but the therapists at my clinic ran into the same problem. Administration increased the number of intakes per week in order to get more patients in and reduce the wait time for new apppintments. But that doesn't actually address the demand as seeing patients monthly for a handful of sessions isn't actually treatment. There is an obligation to treat the patients you take in as that's what you promise them and charge them money for.

Ultimately, we convinced administration that they were wrong by coming up with our well thought out proposed schedule. What helped it to stick was having one administrator recognize that demand could never fully be met so we shouldn't try, and a fancy looking mathematical model of the clinic I set up to determine the optimal number of intakes per week to maintain a full schedule while providing good care (it helps that most people don't understand math and so just accept what I say). Usually, you make more money per hour of follow ups than intakes, so the plan makes financial sense too. If you'd like, I can share my modeling with you.

 

[Therapist4Chnge]

Usually, you make more money per hour of follow ups than intakes, so the plan makes financial sense too. If you'd like, I can share my modeling with you.

I’m curious about this part, as the $ seems to skew to intakes (as do the RVUs for ppl who use them).

 

[hamstergang]

I’m curious about this part, as the $ seems to skew to intakes (as do the RVUs for ppl who use them).

At my place, intakes make more $ and RVUs than follow ups but also take more time. It's close, but the numbers I had put follow ups ahead of intake on an hourly basis.

 

[smalltownpsych]

I have always had the same problem with patients coming to see me and ending up working harder than colleagues. I now work in a place where I get compensated based on productivity and now when I work that hard at least I get paid and paid well. Learning how to maximize my energy and cope with heavy caseload over the last four years has been quite the process. One thing that I have found for myself is that the maxim of "never work harder than the patient" becomes much more important when you are consistently seeing over 30 patients a week. Especially true with intakes. Some of those patients who don't know why they were referred and don't really want help in anyway can be very draining. With patients like that I try to keep it light and get 'em out after conducting basic due diligence as far as risk assessment or ruling out serious mental illness.

 

[Hawkeye11]

I'm a psychiatrists, but the therapists at my clinic ran into the same problem. Administration increased the number of intakes per week in order to get more patients in and reduce the wait time for new apppintments. But that doesn't actually address the demand as seeing patients monthly for a handful of sessions isn't actually treatment. There is an obligation to treat the patients you take in as that's what you promise them and charge them money for.

Ultimately, we convinced administration that they were wrong by coming up with our well thought out proposed schedule. What helped it to stick was having one administrator recognize that demand could never fully be met so we shouldn't try, and a fancy looking mathematical model of the clinic I set up to determine the optimal number of intakes per week to maintain a full schedule while providing good care (it helps that most people don't understand math and so just accept what I say). Usually, you make more money per hour of follow ups than intakes, so the plan makes financial sense too. If you'd like, I can share my modeling with you.

I’m dying with curiosity on the math model.

 

[hamstergang]

I’m dying with curiosity on the math model.

Ok, so I was modeling a clinic under the assumption that patients would come in, be seen once weekly for a set number of sessions, and then be discharged. Some patients would go on to have monthly booster sessions for some time as well. The question I set out to answer was, given this set up, for set values of several variables, how many intakes and follow ups per week need to be scheduled in order to maintain a constant flow (i.e. same number of intakes per week as discharges)? This would allow you to remain full but not overfill.

There are a few variables I could think of that I didn't include, but they wouldn't influence the conclusion very much and so ultimately don't matter. The variables that we have to give values to aren't set values -- your no-show rate varies from day to day, week to week, month to month, yet we have to give it a single value. The purpose of my model is to give a rough idea of how to split up your clinical hours. Ultimately, the true values you use may be adjusted depending on how things actually flow in the real world after you get things going.

Final note, doing the number of intakes given by this model will keep you full if you already have the right number of patients already moving along the specified number of weeks of therapy. If you have fewer patients (including starting with 0), this number of intakes will eventually get you to the right number to stay full. If you have more patients, then you won't have sufficient room to give weekly sessions to all these intakes and you'll continue to grow out of control -- this only works if you go through a purge first.

Variables:
To be calculated:
F = total number of follow up slots per week
I = total number of intake slots per week

To be set by you: (all % are to be expressed as decimals from 0 to 1)
Tf = length of time for follow up (in hours)
Ti = length of time for intake (in hours)
H = hours available per week for intakes and follow ups (hours you're at work minus meetings, lunch, administrative time, etc)
L = length of treatment (in weeks)
De = % of patients who DON'T drop out by the end of treatment (so if De = 0.75, then 25% of patients drop out by the end of L weeks)
Ni = % of patients who DON'T no-show for the intake
K = % of patients who actually proceed from intake to treatment (some patients may want an eval only, some you may hospitalize on the first visit, etc)
Nf = % of patient who DO no-show for follow up appointments each week
B = % of patients who need to proceed to monthly boosters after L weeks of treatment
M = number of months needed for booster sessions

Equations:
F = K*Ni*I*(De*B*M+((1-De^(L/(L-1)))/(1-De^(1/(L-1))))+De*Nf*L)
I = (H-Tf*F)/Ti

 

[hamstergang]

Equations:
F = K*Ni*I*(De*B*M+((1-De^(L/(L-1)))/(1-De^(1/(L-1))))+De*Nf*L)
I = (H-Tf*F)/Ti

Hmmm, in reviewing this post, I realize I stopped 1 slide in my powerpoint before the end. The more useful equation (which really just puts the above 2 equations together) is:

I = H/(Tf*K*Ni*(De*B*M+((1-De^(L/(L-1)))/(1-De^(1/(L-1))))+De*Nf*L)+Ti)
or to cut down on parentheses for more easy reading, let X = 1-De^(L/(L-1)) and Y = 1-De^(1/(L-1)), then:
I = H/(Tf*K*Ni*(De*B*M+X/Y+De*Nf*L)+Ti)

That lets you calculate I from the variables you set, and then:
F = (H-Ti*I)/Tf

Proving the above equations took me 30 slides, so no one questioned me on it. I believe it to be true, and it produces numbers that seem to make sense.