Originally posted on Therapy Reimagined (https://therapyreimagined.com/making-decisions-now/)
Many of us are two months into quarantine and have settled into a new normal. There are people who are working from home, have shifted to 100% telehealth, and others who have navigated CDC and WHO guidelines to keep going to work or seeing clients in their office. We have transformed how we live to work to decrease the impacts of coronavirus on our health and on our livelihoods.
Now, it seems that we’re not going to be returning to normal any time soon. Careful physical distancing measures or extended “safer at home” orders are causing many to worry that our lives will never be the same. The economy is struggling and we are faced with the next epidemic: a mental health crisis that many don’t feel our communities are prepared to face.
In sorting through the mountains of information to make the difficult decisions needed now, there are different algorithms that leaders are using to make decisions. One that seems simple and helpful is one that I heard the Los Angeles Mayor, Eric Garcetti, talk about recently: What is the need? What is the risk? How much risk can we mitigate with safety measures?
Let’s take a look at these questions based on decisions many #moderntherapists are facing.
Should I see clients in my office now?
This is a really common question we see popping up all over the FB groups, so Curt and I did a recent podcast episode on our podcast, The Modern Therapist’s Survival Guide on things to consider. There are also some really great resources from the APA and from a couple of our #moderntherapists Kelly and Miranda, about this topic. So rather than go into the nitty gritty on what you will need to do, let’s look at our questions to start you thinking about your particular choice:
What is the need?
The needs for in-person services are both for the clinician and for the clients. Clinicians may need to provide in-person services for financial AND emotional reasons. A number of therapists had significant drops in their caseload when shelter in place orders hit, so adding in-person option may have been necessary financially. There are also clinicians who have found staying at home and providing online therapy personally unsustainable and psychologically draining.
For clients, many do not have adequate technology or access to high speed internet, so telehealth has been unsatisfying half video half phone sessions. Other clients have no privacy or fear sharing their mental health journey with family members or both. A number of clients are not appropriate for telehealth and need in-person treatment to stay safe.
If you feel yours and your clients’ needs are high, it may be important to weigh risk and safety measures. If the needs are not high enough – you may want to consider staying home with your trusty telehealth platform.
What is the risk?
The risks for in-person therapy have been talked about quite a bit. We know that the largest risk for in-office therapy is the chance for transmitting covid in an enclosed space. There are also risks for clients’ privacy if there is a track and trace protocol, meaning that if one of your in-office clients has covid, you’ll probably have to notify public health officials of all the rest of your clients who were in the office recently.
How much risk can you mitigate with safety measures?
For guidance on this, I highly recommend that you check out the CDC or OSHA guidelines. It seems with active measures, you can mitigate some risk, but will still need to include language in your consent for treatment and talk with your clients about the risks.
Each of us will have to weigh the needs, risks and safety measures to determine if we move forward either in whole or in part. Remember, if you decide in-office therapy is required, it doesn’t mean that you need to do bring all of your clients into the office. The decision is up to you and there isn’t a right answer.
Should I adjust my fee or take insurance?
Many of us are feeling called to provide greater access to clients now when our communities are facing more mental health challenges. Current clients may have lost their jobs or have seen other financial hits and can no longer afford weekly, full fee therapy. For some, caseloads (and income) have dropped precipitously. For many, there is the specter of a long-term economic crisis (that may rival the Great Depression) that is shaking their belief in their current business model. Should we look to sliding scale and insurance as the answer?
What is the need?
For therapists, keeping stable income can be important. Having an insurance, sliding scale, or hybrid practice can help do that. Another need is for time to manage family matters (childcare, ailing for sick family members, etc.) that may take precedent. Each person’s needs are different, so it is important to look at how many clients you are able to see successfully, how much money you need to make during this time, and, therefore, what your average hourly rate needs to be. The math is a lot more complicated, but to give you a simple equation: You can add up how much you need to make weekly (what you need to bring home plus what business expenses you need to cover every week) and then divide that by the number of sessions you can do consistently. I typically schedule more sessions than I need because attendance rates are usually about 80-90% of scheduled sessions. For those who are visual:
WEEKLY TAKE HOME INCOME + EXPENSES
NUMBER OF ATTENDED SESSIONS EACH WEEK
If you’re able to get to a number that is between $80-$110 per hour, you can probably do some insurance or sliding scale. If you need to make greater than that per hour, you will probably need to do mostly full fee (or increase how many clients you see).
For clients, the needs are more complex. Some clients will highly value therapy and will continue to seek out and sustain therapy at full fee. For some, therapy is a luxury and will only be used when they are in crisis. When insurance covers most of the cost or fees are within easy range, it is likely that clients will continue with treatment long term. We know that more and more clients will need therapy (with the fears, isolation, and struggles we are going through as a society), but we are still going to have to see how many clients will pay for therapy in challenging economic times. Assessing the need for your area and your target population will be important to consider. Some areas will likely switch to all insurance (if they can find therapists). Other areas may want to avoid having a record of therapy due to privacy and other concerns. Look into how your clientele is approaching the idea of therapy during these times to fully assess the need.
What is the risk?
The risks are often very individualized here. For clinicians who shift their business model, one risk is that they will have trouble shifting back if they want to. Additionally, adding clients at lower fees (whether through sliding scale or insurance) may mean working longer hours and increasing risk for burnout as well as potentially decreasing the ability to meet longer-term financial goals. For clinicians who remain 100% private pay at full fee, there is a risk that they will have trouble maintaining a full caseload or will need to invest in more marketing than usual, leading to income drops.
For clients, the risks of not having accessible mental health are known. And – just because there is a need, doesn’t mean you have to fill it in a way that doesn’t serve your needs or is unsustainable for you. Take a listen to our episode on Gaslighting Therapists for more on that.
How can you mitigate the risk?
We want to balance providing access, earning money, and taking care of ourselves. The ways to mitigate the risks are to make sure that you only take as many clients you can, while keeping the average hourly rate acceptable. Make sure that you’ve planned to give yourself enough downtime and enough income to sustain yourself. For some, that will mean increasing marketing for higher fee clients, for others it will mean limiting the number of insurance clients you take. It is so important to understand your unique situation and to be able to plan for success rather than react and get caught in an unmanageable schedule and an unsustainable financial situation.
How do I manage all of the challenging decisions I’m faced with during these times?
When you’re not sure which way you want to go, it can be so useful to look at your needs, the risks you’re facing, and how you can mitigate those risks. But sometimes that is confusing. So – it can also be useful to talk to trusted advisors and read or listen to advice. In fact, there are so many other questions people are grappling with at this point that I’m sure we’ll be back sharing our thoughts and what we’ve learned. In the meantime, come together in community (like our Modern Therapists Group) to make sure you’re getting support from others who will empower and support you.