Before You See Your First Client

55 Things Counselors, Therapists and Human Service Workers Need to Know

Howard Rosenthal

• Publisher: Routledge
• Year: 2005
• ISBN:
  9781135929619
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Before You See Your First Client begins where courses, workshops, training seminars, and textbooks leave off, providing a candid behind-the-scenes look at the fields of therapy, counseling and human services. In a reader-friendly and accessible style, Dr. Howard Rosenthal offers his readers 55 useful and practical ideas for the implementation, improvement, and expansion of one's mental health practice. Based on the author's own personal experiences, the book is written in an intimate and personal style to which inexperienced and beginning therapists can easily relate.

1
Join Forces with a Psychiatrist to Open a Risk-Free Private Practice

Close your eyes — yes, right this moment — and imagine this dream-come-true scenario. You decide to go into private practice. You are sitting in a nice office, perhaps some would even describe it as plush, with a large oak desk, comfortable chairs, and thick deep-pile carpeting. You have a client- friendly waiting room, stocked with the latest issues of the most popular magazines. Soft soothing background music is piped in to further relax and comfort your clients. But wait, it gets even better. You have a kind efficient receptionist who answers your phone calls, books your appointments, files your clients’ charts, keeps your office stocked with pens, stationery, business cards, and even does most of your insurance paperwork. Even more impressive is the fact that you have a steady stream of referrals provided for you day after day, week after week, year after year. And best of all, everything I’ve described is paid for by somebody else! And in many cases that somebody else is the local psychiatrist. In other words, you’re not risking a single solitary dime of your own money.

Too good to be true you say? Think again! Many counselors and therapists wrongly assume that psychiatrists don’t believe in counseling, therapy, or testing and don’t make referrals. The truth is, however, that many psychiatrists will do everything depicted in the aforementioned fantasy — and more — if they find a nonmedical helper they trust.

Neophyte counselors fresh out of graduate school or those who are new to private practice are often surprised to discover that some (though certainly not all) psychiatrists will only refer to a counselor or therapist with whom they have a financial arrangement. By a financial arrangement, I mean that the psychiatrist will collect a sizable amount of money for every client the therapist sees. This, of course, means that the psychiatrist could be sunning and funning in the Bahamas while you are pumping up his or her bank account by seeing clients. It is commonplace for a psychiatrist to take 40 or even 50 percent of the money collected. That is to say, if you see a client for $80, then you will receive $40 less taxes as does the psychiatrist. Since the act of “fee splitting” is often deemed unethical, the psychiatrist’s attorney or accountant will generally have you sign a contract that stipulates that you are paying 50 percent for the use of the office, billing services, and the office staff. This is often referred to as a percentage cut or a percentage split.

Keep in mind that the counselor would not be getting any of these referrals if he or she was not associated with the psychiatrist in question. Moreover, it is the psychiatrist, not you, who is taking the risk and virtually paying for everything necessary to run the practice. The only thing you can lose is your time. Thus, depending upon how you look at it, these so-called percentage cuts can be a good deal for the counselor as well as the psychiatrist. Moreover, nonmed-ical therapists are now following in the footsteps of psychiatrists and are offering percentage cuts to colleagues — even psychiatrists — who need office space, administrative services, and/or help securing clients. The trick to securing a risk-free private practice is to be assertive. Don’t be afraid to approach a psychiatrist or other professional to make your dream a reality.

2
Don’t Become Married to a Single Referral Source

Ah, the good old days. Susan Gladstone can remember a time when she was proud of her private practice and rightly so. In a three-month period she once snared 148 new referrals, commendable by any standard.

The good news was that all the referrals came from a single source: the inpatient stress unit down the street. The bad news is that about two years ago the unit shut down.

Today Susan now has a caseload she can count on one hand. Three clients to be exact. Susan, like many therapists, was dependent on a single referral source for her client base. Private practitioners, agencies, and hospitals must never be dependent — or married, if you will — to one source for their clients.

Diversify. Branch out. Network, even when you’re doing well, because a marriage to a single referral source is never a marriage made in heaven.

3
Accept the Fact That Salaries in This Field Are Often Unfair

Needless to say I was fit to be tied when I marched — no, make that stormed — into my supervisor two’s office. I had discovered much to my chagrin that three of my workers were making more than I was as their supervisor!

My supervisor listened intently to my tale of woe and then barked back at me. “How in the heck could I feel empathy for you? I’m a supervisor two and all of my supervisor ones, including you, are making more than I am.”

I had to admit I could see her point. Albert Ellis, the father of Rational-Emotional Behavioral Therapy, has warned us of the dire consequences of demanding that the world be fair and perhaps nowhere is unfairness more evident than in social service positions.

I’ll never forget the day I received a call from a practicum student of mine some years ago. She had secured a master’s degree with a perfect 4.0 straight-A grade point average and had secured a position as a counselor in a chemical dependency unit of a hospital.

After four years of dedicated service she came across a horrendous fact that was so shocking she almost choked. As a master’s level therapist her pay scale range was from $18,256 to $24,777. The scale for counselors who were recovering from an addiction was $25,333 to $41,566. In case you missed the point, the top salary for my ex-student, and others who possessed a master’s degree, was less than the lowest possible salary for an individual who was in recovery! Ouch! Worse yet, those who were recovering were not required to have any minimal level of education. Some had never graduated high school!

“I should have lied about my credentials when I took the job,” she told me. “I should have told them that I dropped out of grammar school and spent the sixties whacked out on a drug high.”

Although it has been years since I marched into my supervisor’s office, one thing remains the same. Salaries in mental health, social service, and education are often still grossly unfair.

4
It Pays to Be Assertive When You’re Shopping for Your Salary

Herbert Spencer was the perfect employee and everyone was sad to see him leave. After 19 years of dedicated service Herb was knocking down $33,500 a year. He was repeatedly reminded he was worth a lot more, but the agency could not afford to pay him more on a limited not-for-profit budget. It certainly sounded reasonable to Herb and he accepted the explanation regarding his salary cap like a true gentleman.

One day after Herb retired the agency began the hiring process. Ann Jefferson interviewed for the job. To say that the hiring committee was impressed would be putting it mildly. There was only one problem. Although the salary range of the job was listed at $25,000 to $33,500 (Herb’s salary), Ann made it clear that she had no intention of taking the job for under $35,000.

The verdict? Ann began the job making $1,500 a year more than Herb who spent a major part of his career serving the agency.

Is this fair? No, but as you know, salaries are often unfair in this field. Do the Herbs of this world know this goes on? Rarely, and if they did they would generally feel used and cheated.

Although large agencies, hospitals, clinics, and government jobs may have salary ranges that are set in stone a lot of sites in this field decidedly do not. Therefore, it is imperative to remember that it always pays to be assertive when shopping for a salary. Also, never forget that you (and perhaps even Ann Jefferson) could truly be superior to the former employee such as Herb, despite his or her years and years of service.

The bottom line on this one is crystal clear: If you’re worth more money, say so!

5
Managed Care Panels Often Slam the Door in Your Face

Marty was armed with prestigious credentials — a Ph.D. from a private school, a state counselor’s license, and a certification in mental health.

During the day Marty works for the men’s counseling center at a large hospital. Here he is qualified to see clients from the Brand X Health Care plan. At night, he has his own little private practice. Since the Brand X program is extremely popular, Marty gets a sizable number of calls from clients at his own practice who belong to the program. When Marty called Brand X to verify insurance benefits he was told that he was not a bona fide provider when performing therapy at his private practice office.

Simple enough, he thought. I’ll merely apply as a provider from my private practice address. Much to Marty’s chagrin, he was rejected as a provider! Marty screamed foul play. How could he possibly be qualified at one location but not another when the contract clearly stated that it was not based on ancillary services?

Marty’s story is not atypical. Several years ago I was a consultant for a large hospital. Needless to say, the hospital employees I consulted with had considerably less experience and credentials than I. Nonetheless, some of the same insurance companies and managed care programs that paid the hospital handsomely for outpatient services rejected me as a private practice provider. The moral of the story is that large agencies and influential hospitals often land up on provider panels that will reject you or your agency as a provider.

One managed care organization had rejected me on numerous occasions with the excuse that there were “too many providers in my zip code.” I was repeatedly told that if someone dropped out they would let me know so I could fill the slot. One day the therapist in the office next door to me, who told me she had “connections to get in,” as she put it, dropped out of the program. I immediately (say 30 seconds later) picked up the phone and called to get placed on their panel. When they gave me the song and dance routine about “too many therapists in my zip code,” I told the gentleman I overheard my colleague calling him to drop out just seconds prior to my call. After stumbling over his words, the fellow suggested that perhaps they had miscalculated the numbers of helpers in the zip code and he promised to get back to me. Well I’m glad I didn’t hold my breath because that was about two years ago and I still have never received a phone call.

Managed care — like salaries — is often about as fair as playing poker with a card shark who plays with a stacked deck.

6
Managed Care Firms Dictate Who, When, and How

As a provider on a new panel, Linda Lewis was pleased when she immediately received a referral. Her new client, Debra, was 14 years old and highly disturbed. Since Linda’s contract stipulated that she could only see the client two times she called the managed care company.

“There’s nothing to worry about, Ms. Lewis,” the woman on the other end of the line assured her. “If you read the fine print in your contract you’ll discover that you can request six additional sessions for Debra if you need them.”

“But what if perchance I can’t cure her in eight sessions?” Linda protested. “Debra really has some severe problems.”

After a brief moment of silence, the woman responded. “Look I shouldn’t tell you this but we track everybody on a computer. And well … if you take over eight sessions you’ll never receive another referral from us.”

Linda proceeded to treat the young lady in an appropriate fashion using more than eight sessions and she has never received another referral from the company.

Here are some things managed care can dictate and the concomitant responses you might hear from them in regard to these issues:

• Who can you see. “The client must see somebody on our panel.”
• How many visits are acceptable. “Your client is eligible for six more sessions.”
• When the visits must occur and how much you can charge. “The six visits must take place between July 9 and October 11 and you can only see the client once per week. M.S.W.’s receive $65 for a 50-minute session.” Never mind the fact that your customary charge for this service is $80. The managed care firm — not you — will set the fee!
• What service is appropriate. “You can use psychotherapy, but not biofeedback.”

Many providers in this field consider managed care the enemy, yet it does have a positive side. First and foremost, managed care companies hire a large number of counselors and therapists. In addition, prior to the era of managed care, clients often stayed in treatment for lengthy periods of time that were unwarranted to say the least. Other clients received treatment modalities not considered ideal, since the counselor was not accountable for his or her actions. Most of the practitioners I have spoken with admit such blatant abuse of the system ran insurance costs up and was not the best thing for the patient. These same practitioners usually agree, nevertheless, that managed care’s current policies such as extremely short hospital stays, and its over-emphasis on brevity in terms of outpatient treatment, has gone too far in the opposite direction.

Perhaps what we need is a system that espouses a balanced middle-of-the-road philosophy.

7
The Multicultural Diversity Secret: You Can Work with a Wider Range of People than You Think

My past experience as a supervisor of child abuse and neglect workers taught me an important lesson about diversity. I would routinely get calls from African-American clients who wanted whi...

Table of contents

• Cover Page
• Title Page
• Copyright Page
• Introduction
• 1 Join Forces with a Psychiatrist to Open a Risk-Free Private Practice
• 2 Don’t Become Married to a Single Referral Source
• 3 Accept the Fact That Salaries in This Field Are Often Unfair
• 4 It Pays to Be Assertive When You’re Shopping for Your Salary
• 5 Managed Care Panels Often Slam the Door in Your Face
• 6 Managed Care Firms Dictate Who, When, and How
• 7 The Multicultural Diversity Secret: You Can Work with a Wider Range of People than You Think
• 8 Never Give Any Client Information without a Signed Release-of-Information Form
• 9 You Must Use a DSM or ICD Diagnosis to Secure Third-Party Payments
• 10 The Insurance Superbill Must Have Your Name as the Provider
• 11 Lecturing May Not Flood Your Waiting Room with Clients
• 12 Referrals Received Do Not Determine How Many New Clients You Actually See
• 13 Managed Care Companies Discriminate against Some Counseling and Psychotherapy Theories
• 14 Refer Severely Disturbed Clients for a Medical or Psychiatric Evaluation
• 15 Find Out Whether the Psychological and Psycho-Educational Test Reports You Receive Are Individualized
• 16 Don’t Be Misled by Clients Who Initially Put You on a Pedestal
• 17 Most Professional Certifications Won’t Help You Secure Insurance Payments
• 18 Don’t Use Paradoxical Interventions with Suicidal and Homicidal Clients
• 19 Conduct a Suicide Assessment on Each Initial Client
• 20 Don’t Try to Clone Your Favorite Therapist
• 21 When In Doubt, Use a Person-Centered Response
• 22 Read Ethical Guidelines Before You Even So Much as Hug a Client
• 23 Don’t Rush to Therapeutic Judgment Until You Get All the Facts
• 24 The Number One Therapeutic Blunder: Confronting Sooner than Later
• 25 You Are Not a Failure if You Don’t Land Your Dream Job
• 26 Your Supervisor’s Knowledge and Experience Should Not Be Underestimated
• 27 Use Verbiage Your Client Will Understand
• 28 Be a Better Helper by Networking with Others in the Field
• 29 Grandfathering: The Fast Track for Snaring Licenses and Certifications
• 30 Use Free Advertising to Build Your Agency or Practice
• 31 Helpers Are Mandated Child-Abuse Reporters
• 32 Beyond Confidentiality: Professional Counselors and Therapists Have a Duty to Warn
• 33 If You Want to Work in a Public School, Contact the Department of Education
• 34 Don’t Let a Day from Hell in Court Lower Your Professional Self-Esteem
• 35 Save Your Course Catalogs to Invest in Your Future
• 36 Enhance Sessions by Adjusting Group Treatment Exercises and Using Small Talk
• 37 If a Client Was Disappointed with the Previous Helper Find Out Why
• 38 Use Caution When Considering the “In” Diagnosis
• 39 Don’t Go into This Field to Recount Old War Stories About Your Own Recovery
• 40 Don’t Become Married to a Single System of Psychotherapy
• 41 Be Enthusiastic if You Want to Be a Better Workshop Presenter
• 42 Don’t Try to Clone Your Favorite Mental Health Lecturer
• 43 If a Client You Have Been Seeing for an Extended Period of Time Requests Marriage, Family or Couples Therapy, Consider a Referral to Another Therapist
• 44 Be Prepared to Change Therapeutic Strategies at a Moment’s Notice
• 45 Documentation: The Royal Road to Promotion
• 46 Avoid Dual Relationships Like the Plague
• 47 Insider Tips for a Good Cover Letter and Human Service Resumé
• 48 If You Are Daydreaming, Your Client Will Perceive You as an Uninterested Helper
• 49 Pick a Theory of Intervention and a Job You Believe In
• 50 Despite the Pitfalls, Make Friends with the Media to Promote Yourself and Your Agency
• 51 Writing a Book or Starting a Project? Ask Your Agency First
• 52 Your Employment and Credentials Determine What You Pay for Malpractice Insurance
• 53 Private Practice Is Not a Panacea for Everything That Ails You
• 54 Steer Clear of False Memory Syndrome
• 55 Create an Emotional Trophy Closet to Help You Through a Bad Day
• Conclusion