My “Best Practices” in Psychotherapy: Part I

As I write this, I am 75 ½ years old, doing psychotherapy part-time, and coming off the highest practice income month ever in the history of my 50-year career. I continue to find the work captivating and meaningful. As one of my graduate school professors, the renowned psychiatrist Viktor Frankl, M.D., used to remind us, “We’re all looking for meaning.” He believed it was the primary motivating force in life. I still have the paper I wrote for his seminar on Logotherapy, comparing it to Gestalt Therapy. He liked the paper and wrote positive comments on it. So, I guess for now, money and meaning triumph over retirement. Since I have a measure of life-wisdom and five decades of experience to offer, I continue to be effective with patients.

What policies, modalities, and techniques have I found most useful? In this article, I want to recommend some of my “best practices” that, once employed, were good enough for me to keep in place no matter how much time passed, social norms changed, or psychotherapeutic theories or techniques were abandoned or updated to fit the times.

Allow me to preface what follows: I understand that different patient populations and ethnicities, locations, psychotherapist personality, experience, personal preference, economic conditions, and training models may mean that what works for me may not be right for all. I had the interest and good fortune to be trained in a number of psycho-spiritual modalities that have allowed me to mix and match from a wide basket of resources. Due to time, cost, and interest constraints, I assume that most who have been more recently trained are not necessarily going to be so motivated to explore widely from diverse theoretical orientations. Being taught by and practicing from step-by-step manuals is a very different model than the psychotherapy tools we learned during the creative heyday during the ‘60s, ‘70s and ‘80s.

What I am offering are powerful enough in their impact that I would like colleagues to at least consider these elements, if not implement them into their practice. They are powerful in the sense that they immediately get the patient interested and involved in the process of self-discovery, rather than waiting for the therapist to do the work for them. In my work, these tools help set the frame of the work and unlock new self-awareness and psychodynamic insights that may free patients to make changes in their thinking and behavior. Some of these elements are related to policies and the frame in which the work is done, and some are directly related to techniques.

Policies: Initial Inquiry for Services

I require a brief phone conversation with any prospective new patient. It is not enough for someone to simply fill out a form online and be granted an initial intake consultation. I want to hear the voice of new prospects and how they frame their concerns. I want to know who referred them or how they found my name. Since I do not accept insurance payments directly, I want them to know how much they will be charged and make sure they can afford treatment. If desired by the person, I do provide a statement at the end of each month for those who wish to file insurance themselves.

I want to get a sense of their motivation for engaging in treatment, as well as learn whether they have previously received counseling or psychotherapy. I am not looking to get a detailed history, rather I just want to know if they have had it. All this information is obtained within a few minutes.

I purposely refrain from engaging in an extended phone conversation with prospects—no matter how anxious they sound or how much they may plead. If they are in a true emergency, I refer them to an appropriate resource. This is not only to save time but to also prevent them from mistakenly assuming I am accepting them as a patient. I keep in mind that I am putting myself in potential ethical and legal jeopardy if I become a misguided sympathetic listener, as the caller may assume that listening or giving advice on the phone means we are working together. While some colleagues may offer an initial phone consultation of 15 or more minutes at no charge, I never did this. Again, I am concerned about legal issues of responsibility and do not want to inadvertently lead the prospective patient to believe we have contracted to work together.

If a spouse or other family member is calling to make an appointment for a designated patient, I ask, “Why are you calling for your husband?” Sometimes I will be told that the designated patient is too disturbed or disabled to call for himself. In my experience, more often, however, a spouse calling is an indicator that the patient does not really want treatment but is going along with a demand of the calling spouse. Not surprisingly, in my practice, there is a higher percentage of cancellations when this is the case. To be fair, if not given a referral by a friend or professional, some spouses like to do online research to evaluate a potential psychotherapist and then follow through with a call, in hopes of finding the best person for their spouse.

Intake Session and Frame

From the psychoanalytic/psychodynamic tradition (Langs, 1981), I have made it standard practice to begin and end all sessions on time. Patients can count on my opening the door or admitting them to the Zoom screen on time. I do not begin a session even a few minutes late. While this requires a requisite ability to manage one’s time carefully and a measure of positive compulsivity, beginning and ending on time demonstrates to patients that their time is valued. It encourages them to value literally “every minute” of their expensive session time and to manage their own time carefully, either in planning to be in my consulting room or beginning the teletherapy session on time. It also allows me to keep a precise and orderly schedule. A doctor of any kind admitting a patient on time is a new experience for many, as even the relatively wealthy patients with high expectations that I typically see have been conditioned to sit in a waiting room for up to a half-hour or more before they see the doctor.

Additionally, I do not extend the session when a patient is late; they simply lose the time. Nor do I allow session to extend past the end time, even when patients are emotionally distraught. I charge for late cancellations and no-shows if it is not a bona-fide emergency and require a 48-hour notice for cancellations. Since the pandemic, a recent exception to this strict time limit is when there is a digital connection problem on my end, I will offer a few minutes to make up for the interruption.

I encourage new patients to meet for the intake session in the physical office rather than using teletherapy. I have found that the interaction is deeper in the consulting room than online—not just for the intake session but for allsessions. The myriad distractions that may occur for the patient when doing online therapy are much more limited in the consulting room. I also want to see the patient’s full body, observe how they move and shift, see their eye contact, watch for any physical symptoms of anxiety, and any other non-verbal expressions that may be displayed. I ask all patients to turn off their cell phones, so they will not be distracted. I gather basic history during the session, using an intake form that covers the biographical information I want to obtain. And I do this all the old-fashioned way, with pen and paper.

Unlike many practicing psychotherapists and clinical psychologists in general, I no longer administer any inventories, checklists, or formal assessments in the first session or subsequent sessions. Everything I need to know comes from patients telling their history, my clinical questions, observations, my experience with the patient, and our interaction. I gave up doing periodic standard intelligence testing and diagnostic batteries decades ago. For some years, I periodically did what used to be called “projective testing,” where psychodynamic interpretation was required. I went so far as to focus my doctoral dissertation on using the Rorschach Ink Blots. Projective testing is no longer taught in most United States graduate or professional schools or practiced, having become a relic of an earlier era (Piotrowski, 2015). It went out of fashion in step with the psychoanalytic theory and practice from which it arose.

Fairly often, prospective patients have completed their “homework” before we meet for the intake session by going to our website and reading about my theoretical orientation, specializations, and publication history. I tell them they can expect me to be active and that I do not just sit back and listen without much response. I tell them this because some who have never been in psychotherapy have an outdated and stereotyped notion of the psychoanalytic frame that a psychotherapist listens passively with occasional comments. I want them to know they can expect a dialogue between us, even though the focus will always be on what is of interest or concern to them, not me.

At the beginning of the intake session, I have new patients sign a Consent to Treatment form. I assure them everything they tell me is confidential, aside from the legal limits of being a danger to themself or others and the other mandated exceptions. I hand them a printed copy of my office policies to take with them. I suggest that in the same way I must honor confidentiality and cannot tell anyone I know them without their express written and verbal permission, they should be careful what they tell anyone, including a spouse, about the contents of the session. I want patients to have the mental freedom to ponder what we discuss without having to tell anyone or solicit others’ opinions.

I invite prospective patients to ask any questions they may have as we go, as I want them to make an informed decision as to whether they think I can help them. I tell them we will not go too deeply into their concerns the first session but gather information and then together make a decision at the end as to whether we want to continue.

Unless they make it clear during the inquiry call that they only want a consultation, I do not take on anyone new who will not commit to weekly sessions, as I have found over the years that I cannot have my greatest impact with less than this frequency. I will, however, cut back with patients after a lengthy period of treatment by dropping the frequency to every other week or less when they request. If we decide to engage, I tell patients we will take a few sessions to see how it goes and then evaluate. I do not want them to feel locked into ongoing treatment when they do not know what they are signing up for. I also want to reserve the right to end the treatment if for whatever reason, I don’t think I can be helpful to them or it is not a good therapeutic fit.

Boundaries

I have always maintained a strict policy of not engaging in any kind of socializing with patients. I do not go to patient weddings, out for coffee, attend special occasions or funeral/memorial services. My refusal to socialize outside the office may not be initially understood but makes sense after I explain how I am bound by professional and ethical guidelines that have been put in place for a good reason. This policy extends to patients who have terminated. Since they may choose to return for further treatment in the future, I make it clear that socializing is not possible. I will accept relatively inexpensive holiday gifts from long-term patients who I know would feel offended if I refused their gift, as it is a way to thank me for my help beyond payment for services.

With a few exceptions over the years, I have refrained from engaging in any kind of bartering for services. It is too easy for there to be disappointment in weighing the exchange of my services for whatever they may be offering. In addition, it is possible with bartering for it to turn into a dual relationship, which I want to avoid, even though dual relationships are not considered unethical.

I require payment for services at the time they are rendered. Pre-COVID, this meant a check or cash was handed to me by all patients as I do not accept credit card payment. During COVID and beyond, payment has been almost one hundred percent direct bank-to-bank transfer through Zelle or a similar application, like Pay It Now. This method is not only fast and efficient for all parties but also provides a measure of privacy that cannot be matched when a third party has access to the patient’s information. I should note that I am able to use these applications because I am not filing any insurance claims or doing anything online related to patient record-keeping. If you are accepting and filing insurance claims online, you should use a HIPAA compliant alternative, like Stripe. A “best practice” is to refrain from ever allowing an outstanding balance to accumulate. It can quickly ruin the therapeutic relationship should the patient be unable to pay it off. At worst, it may result in the patient angrily terminating and then the psychotherapist having to file a complaint in small claims court. This is a waste of time and money and too often results in never receiving the balance due even when you may win the case, as you may be forced to garnish the wages of the patient in order to get paid. Ethics experts have always warned against filing a small claims case against patients for unpaid balances because it can trigger the patient retaliating with a formal complaint to the state board. That is why it is in your interest to make sure your compassion for patients does not sway you toward allowing outstanding balances to accumulate or any other behaviors that may compromise a professional relationship. Being firm in boundary setting has contributed to my never having had an ethics complaint filed against me by any patient over the course of my career. Now that we have identified some of my best practices related to policies, intake procedures and the initial session, let me move on to some techniques as they related to psychotherapy interaction. See part II of this article linked here.