Therapists refusing to see parents at intake...

[DD214_DOC]

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So I'm supervising a clinic/service now and am encountering lots of fun on only my second day. I wanted to run this by you guys to get your thoughts.

I'm the only psychiatrist in the clinic which is composed of two psychologists and several LCSW therapists. The psychologists and LCSW's break their intakes into two parts -- an initial parent-only intake, and a subsequent intake for the child/adolescent. The issue is that if a parent shows up to the parent intake with the child (who by policy cannot wait alone in the waiting area until a certain age), the therapist refuses to see the parent at all and makes them reschedule. It takes weeks to get an initial appt here, so this usually ends up creating an angry parent that I then have to deal with as the supervisor.

Thoughts on this? Personally, I think they can still make use of that time even with the kid present.

 

[PikminOC]

Supervise? Really? What control do you actually have?

 

[smalltownpsych]

Seems a bit unnecessarily rigid to me. I prefer to meet with parent and child separately for several reasons, but if that isn't possible then I can think of some reasons why it can be good to meet with them together as well. It could be a boundary setting thing and if that is the case, then this needs to be made clearer to the parents upfront. I personally would not make this a boundary issue and would flex with whatever the clinic policy was. If it were me, I would meet with them all and see if you all can come up with a better plan on how to handle this situation in the future.

 

[DD214_DOC]

Supervise? Really? What control do you actually have?

I should have been more detailed. I'm the clinic and service chief.

 

[DD214_DOC]

Seems a bit unnecessarily rigid to me. I prefer to meet with parent and child separately for several reasons, but if that isn't possible then I can think of some reasons why it can be good to meet with them together as well. It could be a boundary setting thing and if that is the case, then this needs to be made clearer to the parents upfront. I personally would not make this a boundary issue and would flex with whatever the clinic policy was. If it were me, I would meet with them all and see if you all can come up with a better plan on how to handle this situation in the future.

I thought it seemed pretty rigid as well, and intake appointments are already a month out for scheduling. I completely understand the rationale behind separate interviews, but observing them together is also very useful (sometimes more so). It may be a boundary thing, but there's also a secondary benefit of not having to do an intake evaluation. Rather than waste an intake appointment and take up a second one, seems more reasonable to use the time for what you can and schedule a parent-only intake afterwards.

 

[smalltownpsych]

I thought it seemed pretty rigid as well, and intake appointments are already a month out for scheduling. I completely understand the rationale behind separate interviews, but observing them together is also very useful (sometimes more so). It may be a boundary thing, but there's also a secondary benefit of not having to do an intake evaluation. Rather than waste an intake appointment and take up a second one, seems more reasonable to use the time for what you can and schedule a parent-only intake afterwards.

That sounds like a reasonable solution. When I was a director, I learned to not lead with the solution that I wanted in a meeting as they would often come to it on their own with less resistance that way. 😉

 

[DD214_DOC]

That sounds like a reasonable solution. When I was a director, I learned to not lead with the solution that I wanted in a meeting as they would often come to it on their own with less resistance that way. 😉

Right. The problem with this, is that for them it isn't a problem -- they don't have to do an intake eval and get a free hour or hour-and-a-half to catch up on other things, and I end up having to deal with the angry parent. They have no reason to want a solution because for them it isn't a problem. For me, the problem is having to deal with angry parents made that way by a practice I don't really agree with.

 

[cookymonster]

If the policy and consequences of not obeying it are clearly explained to the parent beforehand, I don't see what the parents have to complain about. With that said, which usually happens first, the parent intake or the kid intake?
If the kid intake has already occurred by the time the parent intake happens, the therapist should take a minute to discuss and remind the parent about the policy so that they don't show up with the kid next week.
If the parent intake is scheduled first (which to me makes more sense, since usually the parent is seeking treatment), they should be informed before the appointment, but if they show up with the kid, why not offer to switch and do the kid intake instead?

 

[deleted343839]

Thoughts on this? Personally, I think they can still make use of that time even with the kid present.

Does this happen regularly? If so, I would wonder whether the parents are getting clear information. Perhaps sending an appointment letter beforehand with explicit instructions would help keep everyone accountable.

I agree that this policy is overly rigid and with some flexibility and creativity you can usually do something with the time. However, I suggest you meet with the staff to understand how this came to be before reaching a judgment. This could be symptomatic of a power struggle, it could be a response to some historical stuff you should probably know about, or it could just be a pointless rule.

 

[milesed]

Our therapists see them together for the first 1/2 to 3/4 of the meeting, then see the child alone at the end. We never have younger kids alone in the waiting room either as we cannot supervise their safety.

 

[smalltownpsych]

Right. The problem with this, is that for them it isn't a problem -- they don't have to do an intake eval and get a free hour or hour-and-a-half to catch up on other things, and I end up having to deal with the angry parent. They have no reason to want a solution because for them it isn't a problem. For me, the problem is having to deal with angry parents made that way by a practice I don't really agree with.

I guess it depends on whether or not you have some type of authority to change the policies. If my therapists had been causing me that much grief, I would have threatened to throw them out the window. I actually did threaten that once...half-jokingly. 😛

 

[DD214_DOC]

Our therapists see them together for the first 1/2 to 3/4 of the meeting, then see the child alone at the end. We never have younger kids alone in the waiting room either as we cannot supervise their safety.

This is what I do. Intakes are always parent + child, and if time permits I will move to child only for the remaining time and resume child only next session. If I don't get to the child, then the next session is child only. I, personally, am more interested in observing the interaction between the parent and child. Yes, sometimes parents say stupid things about the kids (meaning negative things) or to the kids, but that's very important data, and if appropriate I always immediately interrupt and ask the child about the parent's comment and how it made them feel; sometimes this is the first time a child has expressed how a parents negative interactions affect them. For the older kids and adolescents, I always give the child/teen opportunities to respond or comment on things a parent says about them. Although, with adolescent patients I spend less time with the parent + patient at the initial session and shift more to the adolescent alone.

The, "parent only" intake seems more of a non-physician thing, most likely because we can't utilize E/M codes if the actual patient isn't there.

 

[DD214_DOC]

I guess it depends on whether or not you have some type of authority to change the policies. If my therapists had been causing me that much grief, I would have threatened to throw them out the window. I actually did threaten that once...half-jokingly. 😛

I'm in a larger system that makes it nearly impossible to actually, "fire" someone. My bigger headache is a group of therapists who do not practice within the accepted SOC and previously were never held accountable for it. They regularly utilize therapeutic modalities with no evidence of efficacy with no rationale justification for doing so. Their patients go months like this, with no improvement, and the therapist just continues the same treatment. I'm all for autonomy as a clinician and all that, but when you utilize play therapy for ADHD, Depression, Anxiety, and even PTSD for every patient you see (even 12 year olds) you're wasting everyone's time. So the same patients and parents f/u with me over and over and over with only marginal improvement at best with meds because the necessary therapy to show further improvement isn't being done.

Personally, I think knowingly and willfully prescribing treatments demonstrated to have zero efficacy borders on negligence.

 

[wolfvgang22]

I'm surprised the wait time for a rescheduled new evaluation is only a month. That's pretty good where I come from, where it is a 6 month wait.

 

[DD214_DOC]

I'm surprised the wait time for a rescheduled new evaluation is only a month. That's pretty good where I come from, where it is a 6 month wait.

Yeah, it's not bad. The flip side of that is follow-up appts are 4-5 weeks out, so all of those new patients have to wait that long to see you again.

 

[MacDonaldTriad]

This is the oldest dynamic in the book. As staff believes they are becoming overwhelmed, they invent creative or sometimes overt ways to place barriers to care. Management always wants to maintain easy access to care, and line staff always wants the opposite. Sometimes a little staff protection isn’t inappropriate. It is our job as managers to judge how much of this being overwhelmed is real vs. laziness. If your door is wide open, the need is infinite.

 

[smalltownpsych]

I'm in a larger system that makes it nearly impossible to actually, "fire" someone. My bigger headache is a group of therapists who do not practice within the accepted SOC and previously were never held accountable for it. They regularly utilize therapeutic modalities with no evidence of efficacy with no rationale justification for doing so. Their patients go months like this, with no improvement, and the therapist just continues the same treatment. I'm all for autonomy as a clinician and all that, but when you utilize play therapy for ADHD, Depression, Anxiety, and even PTSD for every patient you see (even 12 year olds) you're wasting everyone's time. So the same patients and parents f/u with me over and over and over with only marginal improvement at best with meds because the necessary therapy to show further improvement isn't being done.

Personally, I think knowingly and willfully prescribing treatments demonstrated to have zero efficacy borders on negligence.

I agree and it is unfortunate how many bad therapists there are. There are evidenced-based treatments for kids and it is more than just play, although play is necessary and can be very therapeutic and when used intentionally can be the actual treatment. It really has to do with being clear what the goals are: emotional regulation, emotional expression, social interaction, following rules, etc. I am not highly structured in my approach by any means but I'm always doing one or of these in the session. It is also helpful to have ongoing conversations with the parents about the progress and things to work on at home and school and then connect the home and school environments to what is going on in the playroom. If they aren't having any of these conversations and can't conceptualize goals and progress, then they are probably not really helping the kids.

 

[DD214_DOC]

This is the oldest dynamic in the book. As staff believes they are becoming overwhelmed, they invent creative or sometimes overt ways to place barriers to care. Management always wants to maintain easy access to care, and line staff always wants the opposite. Sometimes a little staff protection isn’t inappropriate. It is our job as managers to judge how much of this being overwhelmed is real vs. laziness. If your door is wide open, the need is infinite.

Yeah, I get it. I found a pretty simple solution to this. A therapist claimed that they were overwhelmed and wanted something done about it, as it, "will affect patient care". I asked them to show me the data (current panel size, frequency of appts, % unfilled, what access for her is like, etc.) to support that assertion and we will. Haven't heard about it since.

 

[DD214_DOC]

I agree and it is unfortunate how many bad therapists there are. There are evidenced-based treatments for kids and it is more than just play, although play is necessary and can be very therapeutic and when used intentionally can be the actual treatment. It really has to do with being clear what the goals are: emotional regulation, emotional expression, social interaction, following rules, etc. I am not highly structured in my approach by any means but I'm always doing one or of these in the session. It is also helpful to have ongoing conversations with the parents about the progress and things to work on at home and school and then connect the home and school environments to what is going on in the playroom. If they aren't having any of these conversations and can't conceptualize goals and progress, then they are probably not really helping the kids.

The last line is the problem I have. No documented goals, no documented way to measure progress/outcome (probably because it requires goals first), and parents minimally involved. The typical note reads something along the lines of, "kid came to my office, said he was sad, played for 45 minutes, kid then happy and left. con't play therapy, f/u one week".

 

[smalltownpsych]

The last line is the problem I have. No documented goals, no documented way to measure progress/outcome (probably because it requires goals first), and parents minimally involved. The typical note reads something along the lines of, "kid came to my office, said he was sad, played for 45 minutes, kid then happy and left. con't play therapy, f/u one week".

Poor kid shows up sad because he has to see a crummy therapist who isn't helping and then gets happy cause the session is over and he doesn't have to waste his time playing with a lame adult. 😉
In all seriousness though, this bad therapy makes me pretty angry because by the time I see these kids they are jaded to the process because they were already in therapy and it didn't do anything for them. Makes it all the harder for me to help them, but I guess that's why my schedule is always booked solid and I get the big bucks. 🙂

 

[Shikima]

Poor kid shows up sad because he has to see a crummy therapist who isn't helping and then gets happy cause the session is over and he doesn't have to waste his time playing with a lame adult. 😉
In all seriousness though, this bad therapy makes me pretty angry because by the time I see these kids they are jaded to the process because they were already in therapy and it didn't do anything for them. Makes it all the harder for me to help them, but I guess that's why my schedule is always booked solid and I get the big bucks. 🙂

...Or the therapists who do supportive therapy for years, never working on skills. It's amazing in the types of reactions I get when I'm asking what skills are you using?! And then there's the no insight crowd who project like linda blair in the exorcist because it's cloudy and they must have it sunny and bright to feel bad.