Please Hang Up and Call 911

Most of the therapists I know use some version of this language on their voicemail “If this is a client experiencing a medical emergency, please hang up and dial 911 or go to your nearest emergency room.”   I wondered if I really needed this. Of course, I understood we use it for legal reasons, but I thought it sounded strange. I like to understand why I’m doing something in my business as opposed to just adopting a practice that everyone uses.

I decided to call CAMFT and ask them about the greeting. Access to the lawyers at CAMFT is one of the many benefits of my membership. I spoke with Bradley Jordan Muldrow, JD, and I asked him why I needed to use this greeting on my voicemail. Bradley advised me to retain the greeting, he explained that it serves as an important reminder to my clients that I’m not available 24/7. He explained that if a client was calling at 2:00AM, I would not be expected to answer the phone and my message would inform them of their options in a true emergency. He said that the combination of the greeting and language in my informed consent document help to protect me from potential liability, so I chose to retain the language in my greeting.

I took the opportunity to ask another question. When I was an intern (before they were called associates), my supervisor would cover my practice when I was on vacation and vice versa. My voicemail message would state that clients should contact my supervisor in the event of an emergency. I wanted to know if I needed to have another clinician cover for me when I took time off. Bradley explained that I was not responsible for covering my practice during my vacations; all I need to do is create a vacation greeting that includes the same emergency language as my regular greeting.

It’s important that we maintain clear boundaries with our clients and that we can be flexible when it’s clinically appropriate. I encourage my clients to contact me if they are experiencing a non-life-threatening crisis, but I limit these calls to approximately ten minutes. If someone needs more time, I’ll suggest we schedule a session. I’ve only had a few clients who called frequently between sessions and when that happened, I offered them a second weekly session. Of course, your policies may be different based on the types of clients you see and your personal preferences. Now might be a good time to review your voicemail greeting and see if it’s up to date.

Are You Stuck On Your Own Private Practice Island?

Being a therapist in private practice can feel isolating. I’m constantly looking for new ways to widen my circle of support. In 2013 I participated in the two-year NARM training (The Neuro Affective Relational Model); NARM is a psychobiological approach to treating trauma. I’m a member of a monthly NARM consultation group where we present cases and ask questions.

Several months ago, one of my colleagues/friends and I decided o schedule a monthly meeting where we could discuss clinical and business issues. We’ve been friends for over ten years now and are very honest with each other. I enjoy our meetings and sometimes we call/text between meetings.

I schedule individual consultation with other trauma therapists when I need immediate assistance. Being a member of professional organizations like: LACAMFT, WAAT and GPALA helps me to feel connected to our LA community of therapists. Informal consultation is available in our office suite when my colleagues are free for a brief chat between clients.

All this support helps me to deepen my clinical knowledge and reduce the feelings of isolation that sometimes come with being in private practice. Our work is rewarding and challenging, getting the support I need helps me to be a better clinician and a happier person. Are you getting consultation or are you stuck on your own island?

The Price of Self-Care

I’ll never forget my Law and Ethics professor from graduate school, he taught us about the enormous personal and professional responsibility that comes with being a therapist. One of our first assignments was to write a self-care plan, he said that self-care was an ethical issue and that we needed to be in our own therapy in order to care for ourselves and our clients. He stressed the importance of getting enough sleep and enjoying hobbies and activities outside of work; he showed us photos from his rock-climbing trips.

I took Law and Ethics during my second quarter of graduate school, before I had any clients. At the time I didn’t get what all the fuss was about. I already meditated, exercised, slept well and attended weekly therapy. Later in my career when my caseload increased, I realized what my professor was trying to tell us. Our work requires deep mental concentration and somatic attunement, and it can take a toll on our brains and bodies.

One of the greatest challenges for me is sitting in my chair all day. In my prior career, I could get up and stretch or walk down the hall at any time. I invested in a comfortable, ergonomic chair as soon as I could afford one. Most days I take a walk after lunch, and it feels so good to be outside and to stretch my legs.

Yesterday, I decided to add up what I spent on self-care this month. Here’s my list:

Acupuncture $180 (including herbs)
Weekly psychotherapy $800
Chiropractor $70
Pilates (once a week) $350
Consultation group (monthly) $75
Individual Consultation $180
Grand Total: $1,655

You’re probably thinking that some of my self-care expenses are extravagant, like taking individual Pilates once a week. I’m fifty-five years old and although I have a great chair, my back feels tight after sitting all day. I’d like to keep working, hiking and running, well into my old age, and Pilates has strengthened my entire body, and improved my posture. Maybe your back feels fine, and you don’t need Pilates or a chiropractor, or your Chi is balanced, so acupuncture is unnecessary. You might prefer to get a massage or practice some other form of self-care.

Being in my own personal therapy is non-negotiable, and as I continue to see my own growth, I’m reminded of the reasons why I became a therapist. I’m in a monthly consultation group, where I can present cases and learn from my colleagues and I get individual consultation as needed.

I left graduate school with over $50,000 in loans. I realized early on that if I wanted to rent a nice office, pay off my loans, invest in quality trainings, and take good care of myself, I would need to charge my clients a healthy fee. I’ve noticed that many therapists shy away from talking about money, I’m on a mission to help therapists get comfortable talking about this topic so we can help ourselves and our clients.

These numbers may seem overwhelming to you if you are just starting your practice; you may need to wait until you can afford some of the services on my list or you may need different things. There are numerous ways to take care of yourself that don’t cost any money. One of my favorites is spending time with my neighbor’s dog Mabel, a Newfoundland who greets me with 120 pounds of pure, drooling, love when I get home. What do you like to do for self-care?

I’d love to continue this discussion, let’s connect on social media or through my website.

How do you unwind at work?

Many professional athletes have specific pre-game routines. Serena Williams ties her shoes the same way before each match. Also, on her first serve, she makes sure to bounce the ball exactly 5 times and twice on her 2nd serve. My pre-game (pre-client) routine consists of exercising in the morning, followed by meditation. When I arrive at the office, I review my calendar for the day and briefly scan my client notes.

Lately I’ve been trying to expand my “between-client” routine. My friend Nora McIntire is an acupuncturist who created a short Qi Gong video that I use when I’m feeling tired in between sessions. Sometimes I take out my yoga strap and tend to my very tight hamstrings. I also have two crystals that I pick up and hold when I want to feel grounded. Other times I’ll step outside for a few moments to feel the sun on my face and take a few breaths; I need different things at different times of the day.

Every day I take ninety minutes for lunch, so I have time to eat and go for a walk. After work, I sometimes decompress by watching an old Seinfeld episode or taking a hot bath while reading a good book (no psychology books allowed!).   

What do you do between sessions?

Photo by Andrew Tanglao on Unsplash

To Slide or Not to Slide

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As mental health professionals, our business model is unique (code word for strange) because our clients know that some therapists are willing to offer a sliding scale. Most healthcare practitioners do not offer to adjust their rates, can you imagine asking your physician if she is willing to slide?

When I started my private practice as an intern, I offered my perspective clients a lower rate while I was building my practice. Now that I’m licensed, I prefer to offer reduced rates to my existing clients. If an existing client is experiencing a financial crisis like unemployment or a medical issue, we discuss it and come up with a lower fee. We explore their feelings about the fee adjustment, and we agree on a future time to revisit the rate; this discussion often reveals valuable clinical material. Several of my clients are freelancers who go through long periods of time between jobs, and they appreciate my willingness to reduce their fees during those times.

If a prospective client calls me requesting a low fee, I refer them to my associate or to a training site. I prefer not to “slide” for new clients with the exception of a referral from a friend or someone who is interested in both individual and group therapy. I choose to volunteer in other ways like offering pro bono Brainspotting sessions to people in my community who have experienced trauma and cannot afford therapy.

Here are some of the questions you might ask yourself prior to deciding whether to adjust your fee:

What are your financial goals for this year? How much do you want to earn? Do you have any student loan or other debt to pay off?

Is this client presenting with symptoms you are comfortable working with, or will this client require extra attention between sessions?

How many low fee clients do you have in your practice?

Do you feel worthy of asking for your full fee?

When was the last time you raised your fees?

If you are interested in learning how to make better financial decisions for your business, join me in June for my 10-week live online class- “The Prosperous Professional.”  This class is appropriate for pre-licensed and licensed therapists, acupuncturists, chiropractors, clinical dietitians, and other healing professionals. To learn more, go to https://mariagray.net/prosperous-professional