The Ethics of Scheduling

Therapists' ethical obligations apply to scheduling as well as treatment.

Posted Sep 14, 2012

In my practice, scheduling takes up a good deal of time.  Fielding and responding to emails and calls from prospective clients, determining dates and hours that work for both of us… it is part of the job, and not a small one. 

Fortunately, it’s a part that I enjoy, particularly the rapport that begins to be established in these initial conversations, which always serves to strengthen the working relationship.

I’ve considered moving to an online scheduling system.  There are a number of good ones that allow clients to sign themselves up for sessions, as well as to pre-pay.  It would certainly be less work for me.  

Yet I’ve chosen not to go this route, as it doesn’t provide for the personal connection, take into account scheduling adjustments and slot-swapping, or accommodate for pro bono and reduced-rate cases.

Bottom line: while the system would certainly make my life easier, I don’t feel that it serves the best interests of my clients.

Another scheduling model has started to become popular here in New York and beyond: 'the weekly spot’.  And I am concerned that it too, while benefiting the scheduling and accounting of clinicians tremendously, does not necessarily serve the needs– or even the treatment– of clients. 

Just last week, I heard of two such cases.  In the first, a singer I work with, who has been seeing her therapist for almost three years, expressed a desire to cut back to every other week.  She was feeling more empowered and confident after their and our work together, and was ready to move further from understanding into autonomous action.  As well, their time together had begun to feel redundant and less impactful, an additional cue that it was time to move on.  

The therapist’s response?  Not possible.  With no reference to a therapeutic model or the singer’s specific treatment, it was made clear that she would either have to come every week at a set time, or not at all.  Everyone gets a ‘slot’ and you either commit to a long-term place or not.   

Interestingly enough, when the singer missed a week while on vacation, she was informed that she’d need (again, no reference to treatment model) to make up that time by coming in twice the next week. Apparently, the ‘once a week, locked in slot’ had some flexibility… when it suited the therapist. 

In the second case, the therapist not only required a fixed weekly, long-term time, but as well, insisted that the client pay whether or not he could make it– even with advanced notice.  For set-time clients (all of them) there was no cancellation policy. 

Uncomfortable with the arrangement as he was, this man still chose to ‘sign up for a slot’, given that he was only responsible for a $20 per-session co-pay.  He reasoned that if he missed a day, it wasn’t such a big deal financially.

How much of this type of reasoning has led to the allowance for and prevalence of this model? 

The second therapist at least had the decency to say that her system was not based on a treatment modality, but rather, was her preferred scheduling arrangement.  The first therapist said only, ‘it’s best this way’. 

Best… for whom?

For starters, the efficacy of the weekly model is no longer certain.  One hour, once a week has come to us as a trickle-down from psychoanalysis.  While good work can certainly be done in weekly and higher frequency engagements– within a variety of treatment frames– it is not a therapeutic given. 

What’s more, the idea that the weekly work will continue indefinitely sets up an expectation that the client needs long-term help.  As expectation so often leads to experience, there is now an indefinite amount of time that this person– regardless of the issue– will live as a patient.    

Not everyone needs weekly therapy for two years.  To suggest and more, to demand that this be a condition of treatment is unconscionable. 

It’s not just therapists.  Insurance companies require a diagnosis after the first session of treatment as a condition of payment– a diagnosis which goes and remains on the patient’s medical record.  Is this in the patient’s best interest?  Is an accurate diagnosis even possible within 50 minutes?

All of this points to a trend to place the economic interests and functional concerns of the industry above the therapeutic needs and rights of the people our industry is ethically bound to serve.   

Yesterday, I ran into a friend who encountered a similar ‘long-term, weekly, pay-regardless slot’ offer from a new therapist.  Upon hearing of her policy, she politely declined.  To which the therapist said, “OK, what would you like to do then?” Apparently, some therapists’ policies are flexible; if you can’t get 52 weeks of guaranteed income, why lose the account entirely? 

Thankfully, my friend spoke up.  But what about those who don’t think to ask whether a therapist’s policy is firm or flexible?  What about people who– in a place of crisis or concern– are either too distracted, too intimidated, or too desperate for treatment to ask? 

If we were talking about a massage therapist, a manicurist, or a personal trainer, it would be an entirely different matter.  In our free market economy, everyone has the right to set their rates and scheduling policies as they see fit.  

However, in the counseling profession, we are not only dealing with the laws of supply and demand and our own professional goals.  We are also bound to serve the best interests of our clients in accordance with ethical guidelines, as well as required to honor and not manipulate the power dynamics inherent in the counselor-counselee relationship.

With no therapeutic treatment plan backing it up, demanding that people come weekly, pay regardless, and remain indefinitely is in violation of these agreements.    

Jennifer Hamady is a voice coach and counselor specializing in emotional issues that interfere with self-expression. Click here to learn more about her book: The Art of Singing: Discovering and Developing Your True Voice, heralded as a breakthrough in the psychology of personal and musical performance.

Click here to follow her on Twitter 

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