Thriving In Private Practice Thriving In Private Practice Outside Managed CareOutside Managed Care

Ofer Zur, Ph.D.Ofer Zur, Ph.D.Zur Institute, LLCZur Institute, LLC

www.ZurInstitute.com

Portland, OR, OPAPortland, OR, OPA

April 9, 2010April 9, 2010

© 2010 Zur Institute, LLC. All rights reserved© 2010 Zur Institute, LLC. All rights reserved

© 1997-2010 Zur Institute, LLC© 1997-2010 Zur Institute, LLCAll rights reservedAll rights reserved

Do not copy, share, distribute, post or Do not copy, share, distribute, post or duplicate without written permission duplicate without written permission

form the Zur Institute, LLCform the Zur Institute, LLC

5 Year Ideal Goals–Your Vision5 Year Ideal Goals–Your Vision• Part-time vs. Full-timePart-time vs. Full-time• Private or Group PracticePrivate or Group Practice• Working from Home, Clinic, Office, OnlineWorking from Home, Clinic, Office, Online• Client population: Children/Adult; Ind/Fam; DXClient population: Children/Adult; Ind/Fam; DX• Clinical Orientation/sClinical Orientation/s• Focus: Assessment, Therapy, Eval, ForensicFocus: Assessment, Therapy, Eval, Forensic• Supervise, Teach, Write, Blog, Teach Online Supervise, Teach, Write, Blog, Teach Online • Active in professional organization/s Active in professional organization/s • Hours/Week & Days/WeekHours/Week & Days/Week• $/Month or $/Year$/Month or $/Year

Characteristics of Successful TherapistsCharacteristics of Successful TherapistsPart I - Part I - PersonalPersonal

• Emotionally healthy personEmotionally healthy person• Emotionally present, appropriately involvedEmotionally present, appropriately involved• Flexible: Meets client where they areFlexible: Meets client where they are• Not cold, rigid or dogmaticNot cold, rigid or dogmatic• Uses humorUses humor• Competent clinicianCompetent clinician• “ “Show up” - Dare to be present with clients and Show up” - Dare to be present with clients and respond emotionally or morally as appropriaterespond emotionally or morally as appropriate• Comfortable with self-disclosure & transparencyComfortable with self-disclosure & transparency

Characteristics of Successful TherapistsCharacteristics of Successful TherapistsPart II – Part II – Business PersonBusiness Person

• Skilled manager Skilled manager • Manages well: time, money, billing, taxes, etc.Manages well: time, money, billing, taxes, etc.• Comfortable in marketingComfortable in marketing• Gives ongoing attention to promote the practiceGives ongoing attention to promote the practice• Has public’s confidence in being an expertHas public’s confidence in being an expert• Thrives in the private practice realmThrives in the private practice realm• Manages well responsibilities, burdens, freedomManages well responsibilities, burdens, freedom• Understands & exploits managed care systemsUnderstands & exploits managed care systems• Takes advantage of the InternetTakes advantage of the Internet

Characteristics of Successful TherapistsCharacteristics of Successful TherapistsPart II – Part II – Business PersonBusiness Person

Knows how to run a Knows how to run a successful small successful small

business business

Characteristics of Successful TherapistsCharacteristics of Successful TherapistsPart III – Part III – Clinical SkillsClinical Skills

Generalist vs. SpecialistGeneralist vs. Specialist

Characteristics of Successful TherapistsCharacteristics of Successful TherapistsPart III – Part III – Clinical SkillsClinical Skills

GeneralistGeneralist• Diversify: skills, orientations, populations, Diversify: skills, orientations, populations, marketsmarkets• Intermittent long-term therapy Intermittent long-term therapy • Goes beyond the DSMGoes beyond the DSM• Most general areas:Most general areas:

• Parenting, Aging, major Illness Parenting, Aging, major Illness

• Existential: Meaning, Death, Calling/VocationExistential: Meaning, Death, Calling/Vocation

Characteristics of Successful TherapistsCharacteristics of Successful TherapistsPart III – Part III – Clinical SkillsClinical Skills

SpecialistSpecialist

Identify specific:Identify specific:• Skills Skills • Population – MarketPopulation – Market• ToolsTools

•

Characteristics of Successful TherapistsCharacteristics of Successful TherapistsPart IV – Part IV – Community MemberCommunity Member

• Active in one’s communityActive in one’s community• Visible expert contributorVisible expert contributor• Exemplifies to one’s communityExemplifies to one’s community• Consultant & educatorConsultant & educator• Contribute to local causes: Contribute to local causes:

• Education, HealthEducation, Health

• Recreation & ArtsRecreation & Arts

• Social Justice, PoliticsSocial Justice, Politics

        

Characteristics of Successful TherapistsCharacteristics of Successful TherapistsPart V – Part V – Prevent BurnoutPrevent Burnout

• Diversify activities and interestsDiversify activities and interests• ExerciseExercise• Take time offTake time off• Balance :Balance :

• Work – PlayWork – Play

• Family – Friends – SolitudeFamily – Friends – Solitude

• Mind-Body-SpiritMind-Body-Spirit

• Online – OfflineOnline – Offline

• Nature – Urban Nature – Urban

When I think of $$$$, what is the When I think of $$$$, what is the first thing that comes to mind?first thing that comes to mind?

What, How and Who What, How and Who shaped your relationship shaped your relationship

to to

• Money, Profit & WealthMoney, Profit & Wealth??

Practice: $/TimePractice: $/Time

• $150,000/Year$150,000/Year• $12,500/Month$12,500/Month• 25 Hours/Week25 Hours/Week• 6 Wks Vacation 6 Wks Vacation

$$$ - Hours$$$ - Hours

• Your office is a reflection of who Your office is a reflection of who you areyou are

• Your office also determines how Your office also determines how comfortable people are with youcomfortable people are with you

• How ‘homey’ is itHow ‘homey’ is it• Temperature, size, accessibilityTemperature, size, accessibility• Reflects your take of healing spaceReflects your take of healing space

Your Office & YouYour Office & You• Carefully select: Office location, decor, Carefully select: Office location, decor,

furniture, seating arrangementsfurniture, seating arrangements• Size & shape of roomSize & shape of room• Decide on style of waiting roomDecide on style of waiting room• Neighbors and neighborhood, parking, Neighbors and neighborhood, parking,

accessibility, securityaccessibility, security• General impression of your office General impression of your office

Disclosures in OfficeDisclosures in Office

• BooksBooks

• ArtArt

• CertificatesCertificates

• Family photosFamily photos

• Artifacts, Icons, ImagesArtifacts, Icons, Images

• Not disclosing is . . . Disclosing!Not disclosing is . . . Disclosing!

Home OfficeHome OfficeUnexpected occurrencesUnexpected occurrences

• Children or cats wandering into officeChildren or cats wandering into office• Dogs barkingDogs barking• Neighbors and friends visitingNeighbors and friends visiting• Abusive boyfriend drops in . . .Abusive boyfriend drops in . . .• Alcohol is being served/consumedAlcohol is being served/consumed• Phone ringing - TV blasting – Computers Phone ringing - TV blasting – Computers

humminghumming• Cooking aromasCooking aromas

First Call from a potential client:First Call from a potential client:• Be personal, take your timeBe personal, take your time• Listen well - People like to feel heardListen well - People like to feel heard• Don't rush Don't rush • Be helpful, give:Be helpful, give:

– Something useful-helpfulSomething useful-helpful– Insight, advice, suggestionsInsight, advice, suggestions– Food for thoughtFood for thought–Suggestion for books, Web sitesSuggestion for books, Web sites

First Call from a potential client:First Call from a potential client:• Educate clients about their concernsEducate clients about their concerns

– Give practical suggestionsGive practical suggestions– Normalize, when appropriateNormalize, when appropriate– Suggest solutionSuggest solution

• Give them:Give them:– Referrals & ReferencesReferrals & References– Introduce them to resourcesIntroduce them to resources– Follow up e-mail with links to web sites or Follow up e-mail with links to web sites or

online articles, guidelines, & resourcesonline articles, guidelines, & resources

Managled Care 101Managled Care 101• Educate them about the hazards of managed Educate them about the hazards of managed

care: care: – Privacy!!!Privacy!!!– Control of treatmentControl of treatment– Continuity of treatmentContinuity of treatment– Managed care isn’t associated w/ qualityManaged care isn’t associated w/ quality

• Be prepared with a rehearsed 'mini lecture’ Be prepared with a rehearsed 'mini lecture’ • Be ready to send them links to web sites that Be ready to send them links to web sites that

support your claimssupport your claims• Explain the benefit of private pay therapy Explain the benefit of private pay therapy

‘‘Show up’ on the first call!!Show up’ on the first call!!• EmotionallyEmotionally• MorallyMorally• EmpathicallyEmpathically• PersonallyPersonally• Be transparentBe transparent

FeesFees

• Garry syndromeGarry syndrome• No dealing with insuranceNo dealing with insurance• State your fees in the Office PoliciesState your fees in the Office Policies• Do not bring it up, automatically, in Do not bring it up, automatically, in

the first phone callthe first phone call

Marketing challenges you Marketing challenges you

to present yourself as:to present yourself as:

An EXPERT who can HELP An EXPERT who can HELP people live better, happier, people live better, happier,

healthier, and longerhealthier, and longer

Marketing 101Marketing 101

People pay for what they value:People pay for what they value:

Cars, clothes, houses, vacations, Cars, clothes, houses, vacations, gardeners, hairdressers, private gardeners, hairdressers, private schools, health clubs, personal schools, health clubs, personal

trainers, cosmetic surgery, trainers, cosmetic surgery, acupuncture, relationshipsacupuncture, relationships

Marketing 101Marketing 101

People pay you if they: People pay you if they: • Value Value what they get from youwhat they get from you• Think you are Think you are helpfulhelpful• Like Like what they getwhat they get

Marketing 101Marketing 101

People will perceive you as People will perceive you as an expert who can help an expert who can help and refer clients to you if and refer clients to you if they get a sense of who they get a sense of who you are, your personality, you are, your personality, values, and competencevalues, and competence

Marketing 101Marketing 101

How to position oneself as an How to position oneself as an Expert-Educator who can help?Expert-Educator who can help?

Free lectures on:Free lectures on:• Love – RelationshipsLove – Relationships• Parenting the youngParenting the young• Dealing with teensDealing with teens• Balancing life in a hurried timesBalancing life in a hurried times• Internet/Facebook obsessed childrenInternet/Facebook obsessed children• More . . .More . . .

How to position oneself as an How to position oneself as an Expert-Educator who can help?Expert-Educator who can help?

Articles in local Articles in local NewspaperNewspaper• Local eventsLocal events• Holiday issuesHoliday issues• Specific issues in the community: Specific issues in the community:

Bullying, Domestic Violence, Rape, Bullying, Domestic Violence, Rape, Gangs, etcGangs, etc

• Internet obsessed childrenInternet obsessed children• More . . .More . . .

How to position oneself as an How to position oneself as an Expert-Educator who can help?Expert-Educator who can help?

Call local Call local paper or radio paper or radio station for station for an interview regarding local or an interview regarding local or highly publicized event:highly publicized event:

• Domestic violence, Drug abuseDomestic violence, Drug abuse• School shooting, GangsSchool shooting, Gangs• Rape, Robbery, CrimeRape, Robbery, Crime• Financial crisis, Loss of employmentFinancial crisis, Loss of employment• More . . .More . . .

How Can I Help You?How Can I Help You?

Wow can you help potential Wow can you help potential referral sourcesreferral sources

• Local physiciansLocal physicians• PriestsPriests• School principles and TeachersSchool principles and Teachers• Educational director of Rotary ClubEducational director of Rotary Club• ER - HospitalsER - Hospitals

Overcoming Public Speaking Overcoming Public Speaking ApprehensionApprehension

• CoachesCoaches• ToastmasterToastmaster• WorkshopsWorkshops• RetreatsRetreats• More . . .More . . .

Mangled Care 101Mangled Care 101

• Not being an insurance panel provider can Not being an insurance panel provider can be helpful in obtaining referrals from be helpful in obtaining referrals from physiciansphysicians

– It can reduce their client loadIt can reduce their client load

– Can save them moneyCan save them money• Make practice outside managed care a Make practice outside managed care a

virtuevirtue

Mangled CareMangled Care

Main hazards of managed care: Main hazards of managed care: – Privacy!!!Privacy!!!

National data bankNational data bank

Companies may sell dataCompanies may sell data

Companies may share dataCompanies may share data

– Control of treatmentControl of treatment

– Continuity of treatmentContinuity of treatment

Managed CareManaged Care

Managed Care Presents Potential Managed Care Presents Potential Risks: Risks: – Life insuranceLife insurance

– Health insuranceHealth insurance

– Employment (police, pilot, etc.)Employment (police, pilot, etc.)

– Security ratingsSecurity ratings

Your Web SiteYour Web SiteCreate a Create a helpfulhelpful and and personalpersonal

web site that reflects yourweb site that reflects your

Taste, Style, &Taste, Style, & ValuesValues

Importance of Web PresenceImportance of Web Presence• Business legitimacyBusiness legitimacy• Many people Google you Many people Google you before before

they call youthey call you• Plumbers, physicians, psychics, Plumbers, physicians, psychics,

trainers, dietician, gardeners, trainers, dietician, gardeners, all all have web presence have web presence

How Do People Get to Your How Do People Get to Your Web Site?Web Site?

• Google you Google you before before they call youthey call you• See your web sites See your web sites after after they were they were

referred to youreferred to you• Do comparative shoppingDo comparative shopping• Via directories Via directories

Web Site Should IncludeWeb Site Should Include• Home PageHome Page• ‘‘Contact Me’ Contact Me’ • Directions to OfficeDirections to Office• ‘‘About me’, CV, Personal BioAbout me’, CV, Personal Bio• Mission statement or Philosophy Mission statement or Philosophy

of Treatmentof Treatment

• Resources Resources !!!!!!!!

Home PageHome Page• PhotoPhoto• Name, Degree, LicenseName, Degree, License• Statement of who you are Statement of who you are • What services you provideWhat services you provide• MenuMenu- Short Video (optional)Short Video (optional)

AvoidAvoid• Too much flash or animationToo much flash or animation• Long statement about how good you Long statement about how good you

areare• Testimonials (can be unethical)Testimonials (can be unethical)• Complicated animationsComplicated animations• Too many photo’s of you (unless it Too many photo’s of you (unless it

appropriately fits in the bio)appropriately fits in the bio)

Ways To Construct a Web SiteWays To Construct a Web SiteDo it yourselfDo it yourself* From scratch: Know your staff* From scratch: Know your staff

* Using existing general templates: Google or * Using existing general templates: Google or Yahoo: Often free but may have adsYahoo: Often free but may have ads

* Create a blog: Simple, cheap * Create a blog: Simple, cheap wordpress.comwordpress.com

* Do it yourself by using exiting templates for * Do it yourself by using exiting templates for therapists: www.therapysites.com, therapists: www.therapysites.com, www.successful-therapist.comwww.successful-therapist.com

Hire a Web Designer or a Company Hire a Web Designer or a Company Does not need to very expensiveDoes not need to very expensive

Web Page: On Being HelpfulWeb Page: On Being Helpful

Web Page: TransparencyWeb Page: Transparency

Examples:Examples:Resources Web PageResources Web Page

• 10 ways to . . 10 ways to . . • Beat the Holiday bluesBeat the Holiday blues• Break free of depressionBreak free of depression• Start flying againStart flying again• Jump-start your marriageJump-start your marriage• Assess teen depressionAssess teen depression• Learn from griefLearn from grief

Resources PageResources Page• You don’t need to write the resourcesYou don’t need to write the resources• Provide links to article on other web Provide links to article on other web

sitessites• Link to large organizations are Link to large organizations are

generally not as helpful as direct link to generally not as helpful as direct link to actual articles or guidelinesactual articles or guidelines

• There are millions(!) of free resources There are millions(!) of free resources to choose fromto choose from

Standard of Care is Based on:Standard of Care is Based on:• StatutesStatutes• Licensing Boards’ regulationsLicensing Boards’ regulations• Case lawCase law• Ethics codesEthics codes• Consensus of the professionalsConsensus of the professionals• Consensus in the community/settingConsensus in the community/setting

• The "respected minority" doctrineThe "respected minority" doctrine

Standard of Care Is Standard of Care Is NOTNOT!!

• A standard of perfectionA standard of perfection• Following risk management Following risk management

principlesprinciples• Following psychoanalytic principlesFollowing psychoanalytic principles• Permanent or fixedPermanent or fixed• Determined by outcomeDetermined by outcome• Determined by cost of treatmentDetermined by cost of treatment

Standard of CareStandard of Care

• There is no one textbook or set of rules There is no one textbook or set of rules that define the standard of carethat define the standard of care

• Some argue: “Standard of perception”Some argue: “Standard of perception”• Most of the time the standard of care is Most of the time the standard of care is

determined in court by testimonies from determined in court by testimonies from expert witnesses, hired by opposing expert witnesses, hired by opposing attorneys, who testify ‘against’ each otherattorneys, who testify ‘against’ each other

Proof of Compliance Proof of Compliance with the SOCwith the SOC

• Records!!!Records!!!• Documented Consultations Documented Consultations

–The therapist next door (does not hold The therapist next door (does not hold much weight)much weight)

–Peer consultationPeer consultation

–Arms length consultation with an expertArms length consultation with an expert

–Differentiate: Clinical-Ethical-LegalDifferentiate: Clinical-Ethical-Legal

Why Keep Records?Why Keep Records?• Increase quality careIncrease quality care• Part of the standard of carePart of the standard of care• In case of litigationIn case of litigation• Continuity of care in case of Continuity of care in case of

abrupt terminationabrupt termination

Assume that no records are Assume that no records are immune from disclosureimmune from disclosure

..

Clinical Records - FormsClinical Records - Forms• Office Policies Office Policies • BioBio• AuthorizationsAuthorizations• ConsentsConsents• HIPAA FormsHIPAA Forms• More . . .More . . .

Entries - NotesEntries - Notes• Each sessionEach session• Important e-mails and phone callsImportant e-mails and phone calls• Emergencies, Suicide EvalEmergencies, Suicide Eval• Gifts, Extensive Touch, BarteringGifts, Extensive Touch, Bartering• Dual RelationshipsDual Relationships• Out of Office Experiences: Home visitsOut of Office Experiences: Home visits• Extensive digital communicationsExtensive digital communications

Retaining RecordsRetaining Records

• Retain records as long as it is legally Retain records as long as it is legally mandatedmandated

• Generally, there are no legal Generally, there are no legal requirements to maintain any records requirements to maintain any records beyond the required time unless there beyond the required time unless there is a reason (i.e., Law Suit, WC)is a reason (i.e., Law Suit, WC)

In LitigationIn Litigation

It is often not the therapist’s word It is often not the therapist’s word against client’s wordagainst client’s word

It is often client’s word against the It is often client’s word against the therapist’s therapist’s recordsrecords

HIPAA:HIPAA:

About About

Privacy-ConfidentialityPrivacy-Confidentiality

&&

AutonomyAutonomy

HIPAA HIPAA • Password and firewall on laptop/computerPassword and firewall on laptop/computer• Lock files cabinets and officeLock files cabinets and office• Make sure that files do not show clients’ Make sure that files do not show clients’

namesnames• Use shreddersUse shredders• Document disclosuresDocument disclosures• ““Need to know”Need to know”• ““Minimum necessary”Minimum necessary”• More . . . More . . .

Professional WillProfessional Will

• Who to notifyWho to notify• How to notifyHow to notify• Access to files, computers, officeAccess to files, computers, office• Who takes care of recordsWho takes care of records• Referrals Referrals • MoreMore

Mental Health DirectiveMental Health Directive

• If client dies If client dies • Therapists may not need to disclose Therapists may not need to disclose

records to the executor of the estaterecords to the executor of the estate• Clients should add it to their will or Clients should add it to their will or

living trustliving trust

SubpoenaSubpoena• Neither ignore nor send recordsNeither ignore nor send records• When served do not acknowledge that When served do not acknowledge that

you know or treated the clientyou know or treated the client• Don’t avoid being served a subpoenaDon’t avoid being served a subpoena• Contact client and get a release, when Contact client and get a release, when

appropriate appropriate • Consider source: Attorney vs. JudgeConsider source: Attorney vs. Judge• Careful with test data and protocols Careful with test data and protocols

When the board comes knockingWhen the board comes knocking• Don’tDon’t ignore a board investigationignore a board investigation

• Don’tDon’t talk to investigator w/out an attorneytalk to investigator w/out an attorney

• Don’t Don’t respond to letters from the board respond to letters from the board w/out an attorneyw/out an attorney

• Don’t Don’t assume your innocence will become assume your innocence will become apparent when you talk to the investigator apparent when you talk to the investigator

• Don’t Don’t turn over any material without legal turn over any material without legal adviseadvise

• Don’t Don’t discuss your case with othersdiscuss your case with others

• Don’t Don’t assume: No harm -> No caseassume: No harm -> No case

•

When the board comes knockingWhen the board comes knocking* * CContact your malpractice insuranceontact your malpractice insurance* Contact a knowledgeable attorney * Contact a knowledgeable attorney * Help your attorney identify top expert/s* Help your attorney identify top expert/s* Be active in your defense* Be active in your defense* Prepare for the long run * Prepare for the long run * Focus on self-care* Focus on self-care

**

What To Do Today – What To Do Today – Before Before you are being investigatedyou are being investigated

• Make sure that your malpractice insurance Make sure that your malpractice insurance includes coverage for investigation by includes coverage for investigation by boardsboards

• Preempt board inquiry by:Preempt board inquiry by:

– Keeping good recordsKeeping good records

– Consulting with expert/s on difficult cases Consulting with expert/s on difficult cases

Avoiding Litigation & Board Avoiding Litigation & Board InvestigationInvestigation

• Do good therapyDo good therapy• Connect well with your clientsConnect well with your clients• Keep reasonable recordsKeep reasonable records• In special circumstances, keep extensive In special circumstances, keep extensive

records (suicidality, violence, custody, records (suicidality, violence, custody, forensic, BPD, complex dual relationships, forensic, BPD, complex dual relationships, etc.)etc.)

• Consult, Consult & Consult (peers/experts)Consult, Consult & Consult (peers/experts)

You are always one You are always one borderline borderline

away . . . from away . . . from losing your licenselosing your license

E-Mail in TherapyE-Mail in Therapy• Are E-mails considered psychotherapy?Are E-mails considered psychotherapy?• If I give my E-M must I check it often?If I give my E-M must I check it often?• Does E-M mean I must be HIPAA Compliant? Does E-M mean I must be HIPAA Compliant? • Must E-M be encrypted? Must E-M be encrypted? • What is an E-M signature? What is an E-M signature? • If we E-M to clients, does it mean we are If we E-M to clients, does it mean we are

conducting tele-health or e-therapy? conducting tele-health or e-therapy? • Is an E-M part of the clinical record?Is an E-M part of the clinical record?•

E-Mail in TherapyE-Mail in Therapy• Clarify your thoughts regarding e-mail Clarify your thoughts regarding e-mail

communication with clientscommunication with clients• Discuss the issue of e-mail with clientsDiscuss the issue of e-mail with clients• Office Policies include a section on e-mailsOffice Policies include a section on e-mails• If you are conducting tele-health, follow state If you are conducting tele-health, follow state

laws, and relevant codes of ethicslaws, and relevant codes of ethics• Make sure that each e-mail includes an Make sure that each e-mail includes an

electronic signature electronic signature •

Facebook & TherapyFacebook & Therapy• What is on your Facebook profileWhat is on your Facebook profile• Who is the clientWho is the client• ConfidentialityConfidentiality!!!!!!• Privacy settingsPrivacy settings• Public accessPublic access• Office PoliciesOffice Policies• Dual RelationshipsDual Relationships• Proceed with caution!!Proceed with caution!!•

Make sure your computer has: Make sure your computer has:

• A passwordA password• Virus protectionVirus protection• A firewallA firewall• A back up systemA back up system• Access to Logs (if necessary) Access to Logs (if necessary)

Therapeutic BoundariesTherapeutic Boundaries• GiftsGifts• TouchTouch• Self disclosure Self disclosure • Out of Office Experience (home visit)Out of Office Experience (home visit)• Home OfficeHome Office• Dual RelationshipsDual Relationships• Fees, Bartering, Time, length of sessions Fees, Bartering, Time, length of sessions • Proximity, Spacing, Clothing & LanguageProximity, Spacing, Clothing & Language• E-mails between sessionsE-mails between sessions• Texting or phone calls during sessions Texting or phone calls during sessions • Social Networking & GooglingSocial Networking & Googling

Therapeutic BoundariesTherapeutic Boundaries

• Define Define the therapeutic-fiduciary the therapeutic-fiduciary relationship relationship

• OutlineOutline the “therapeutic frame”the “therapeutic frame”

• Distinguish Distinguish psychotherapy from psychotherapy from social, familial, sexual, business and social, familial, sexual, business and other types of relationshipsother types of relationships

Types Types Of Boundaries:Of Boundaries:

• Boundary ViolationsBoundary Violations

vs. vs. • Boundary CrossingsBoundary Crossings

Boundary ViolationsBoundary ViolationsWWhen therapists cross the line of hen therapists cross the line of decency, violate or exploit their decency, violate or exploit their clients, or intentionally harm them.clients, or intentionally harm them.

E.g.:E.g.:• Sexual exploitationSexual exploitation• Abuse of powerAbuse of power• Financial exploitationFinancial exploitation

Boundary CrossingsBoundary Crossings

Neutral, appropriate, ethical,Neutral, appropriate, ethical,benign or clinically effectivebenign or clinically effectiveinterventionsinterventions

Examples of Boundary CrossingsExamples of Boundary Crossings

• Clinically appropriate self-disclosureClinically appropriate self-disclosure• Home visits to bedridden clientHome visits to bedridden client• Non-sexual, comforting touchNon-sexual, comforting touch• Appropriate giftsAppropriate gifts• Ethical and appropriate barteringEthical and appropriate bartering• Attending a weddingAttending a wedding• Anorexic lunchAnorexic lunch• Escorting clients to important medical apptEscorting clients to important medical appt• Appropriate e-mails between sessionsAppropriate e-mails between sessions

Types of BoundariesTypes of Boundaries

AroundAround the therapeutic the therapeutic relationshiprelationship

Vs.Vs.

Between Between therapists and clientstherapists and clients

AroundAround• TimeTime• Place of sessions: Place of sessions: •Home officeHome office•In or ‘Out-of-Office’ In or ‘Out-of-Office’ ExperiencesExperiences

• FeesFees• BarteringBartering• Confidentiality & PrivacyConfidentiality & Privacy

BetweenBetween

• Self-disclosureSelf-disclosure• TouchTouch• GiftsGifts• Dual RelationshipsDual Relationships• Language & Dress/AttireLanguage & Dress/Attire• Proximity-DistanceProximity-Distance• Social networkingSocial networking• E-mails, texts, GoogleE-mails, texts, Google

Important Self- Disclosure Important Self- Disclosure With Special PopulationsWith Special Populations

• LGBTLGBT• VeteransVeterans• Alcohol and Drug AbuseAlcohol and Drug Abuse• ParentingParenting• Spirituality & ReligionSpirituality & Religion• EthnicityEthnicity• Abused womenAbused women• Small communitySmall community

Therapists’ Transparency Therapists’ Transparency In the Digital AgeIn the Digital Age

• Clients Googling TherapistsClients Googling Therapists• Online Evaluations (Yelp.com)Online Evaluations (Yelp.com)• Social Networking (Facebook)Social Networking (Facebook)• Licensing Boards web sitesLicensing Boards web sites• Complaint web sites Complaint web sites

– (i.e., www.complaintsboard.com)(i.e., www.complaintsboard.com)

The “Google Factor”The “Google Factor”

• Level 1:Level 1: Curiosity (‘Google light’) Curiosity (‘Google light’) • Level 2: Level 2: Due diligence-Thorough searchDue diligence-Thorough search• Level 3: Level 3: Intrusive search to listservesIntrusive search to listserves• Level 4: Level 4: Deceitful: FaceBook, chatroomsDeceitful: FaceBook, chatrooms• Level 5: Level 5: Illegal search - Cyber-stalkingIllegal search - Cyber-stalking

What Can Therapists Do What Can Therapists Do About Internet Disclosures:About Internet Disclosures:

• Expect modern, informed Expect modern, informed consumers/clients to Google youconsumers/clients to Google you

• Be careful with any web postingBe careful with any web posting• Google yourself regularlyGoogle yourself regularly• Sign up for (free) “Google Alerts”Sign up for (free) “Google Alerts”• Evaluate your options regarding Evaluate your options regarding

negative postings about younegative postings about you• . . . Surrender. . . Surrender

The Facebook Dilemma:The Facebook Dilemma:How to respond to Friends requests How to respond to Friends requests

on Facebook?on Facebook?• Consider your profile: Personal vs. Consider your profile: Personal vs.

Professional, or BothProfessional, or Both• Does this constitute dual relationship?Does this constitute dual relationship?• What is the client privy to? What is the client privy to? • Privacy settingsPrivacy settings• Who is the client?Who is the client?• Context of therapyContext of therapy

Phones or TextingPhones or Texting During Sessions During Sessions

• Clients:Clients:

Receiving or making phone callsReceiving or making phone calls

Receiving or sending textsReceiving or sending texts• Therapists:Therapists:

Receiving or initiating phone callsReceiving or initiating phone calls

Receiving or sending textsReceiving or sending texts

Clients’ Phones or TextingClients’ Phones or Texting During Sessions During Sessions

• Minimally disruptive Minimally disruptive • Significantly disruptive & rudeSignificantly disruptive & rude• Can be ‘telling’: Giving therapists Can be ‘telling’: Giving therapists

additional perspective and new additional perspective and new understandingunderstanding

Out-Of-Office ExperiencesOut-Of-Office Experiences1. Part of a Treatment Plan1. Part of a Treatment Plan

–Fear of flying, Agoraphobic Fear of flying, Agoraphobic 2. Unavoidable2. Unavoidable

– Home/hospital visit of bedridden clientHome/hospital visit of bedridden client2. Enhancing Therapeutic Effectiveness2. Enhancing Therapeutic Effectiveness

– School play, Tour w/ an architect, B-BallSchool play, Tour w/ an architect, B-Ball

3. Relationships in the Community-3. Relationships in the Community-DR!DR!–Social relations in small communitiesSocial relations in small communities

4. Accidental encounters4. Accidental encounters–Encountering a client in the communityEncountering a client in the community

Types of Dual RelationshipsTypes of Dual Relationships• SocialSocial• ProfessionalProfessional• BusinessBusiness• CommunalCommunal• ForensicForensic• SexualSexual• OnlineOnline• Others (i.e., Adoption)Others (i.e., Adoption)

Dual Relationships can be:Dual Relationships can be:• Voluntary - Avoidable:Voluntary - Avoidable:

–Large citiesLarge cities• UnavoidableUnavoidable::

–Small-Rural Communities, Sport Psych.Small-Rural Communities, Sport Psych.• Mandated:Mandated:

–Military, Police, Prisons/Jails, CPSMilitary, Police, Prisons/Jails, CPS• UnexpectedUnexpected::

–OnlineOnline. Prime: . Prime: Therapist’s son dates patientTherapist’s son dates patient

Concurrent - SimultaneousConcurrent - Simultaneous

• Therapist and friend Therapist and friend at the same timeat the same time

• Therapist and client attend same Therapist and client attend same church, club, church, or gymchurch, club, church, or gym

• Therapist and client participate in same Therapist and client participate in same professional wks/conference (today?)professional wks/conference (today?)

Sequential - Chronological Sequential - Chronological

• Friendship starts Friendship starts after after terminationtermination• Therapist becomes business coach Therapist becomes business coach

after after terminationtermination• Therapist played tennis or attended Therapist played tennis or attended

a church with client a church with client prior prior to start of to start of therapytherapy

Intensity of DRIntensity of DR• Low - Minimal involvementLow - Minimal involvement

– Shopping in the same food marketShopping in the same food market

– Children going to the same schoolChildren going to the same school• Medium LevelMedium Level

– Meeting every Sunday at churchMeeting every Sunday at church

– Marching in the same political rallyMarching in the same political rally• Intense Level or InvolvementIntense Level or Involvement

– Serving on a committee togetherServing on a committee together

– Playing in a recreation leaguePlaying in a recreation league

Multiple Loyalties & DRMultiple Loyalties & DRPublic agencies, CPS, Prisons, Jails, Public agencies, CPS, Prisons, Jails, Psychiatric Hospitals, Clinics, DMHPsychiatric Hospitals, Clinics, DMH

• Institution vs. ClientsInstitution vs. Clients• Parents vs. ChildrenParents vs. Children• Client vs. CommunityClient vs. Community

Risk Management . . .Risk Management . . .

• Is Is notnot synonymous with ethical principles synonymous with ethical principles• Is Is notnot the same as clinical guidelines the same as clinical guidelines• Does Does notnot define the standard of care define the standard of care• Can be unethical and counter-clinicalCan be unethical and counter-clinical

Ethical Risk ManagementEthical Risk Management• Do whatever it takes to help clientsDo whatever it takes to help clients• Do not harm or exploit clientsDo not harm or exploit clients• RRespect your clients espect your clients • Never humiliate your client or assail their dignityNever humiliate your client or assail their dignity• Place clients' welfare above your fear of Place clients' welfare above your fear of

boards, courts, ethics committees and boards, courts, ethics committees and attorneysattorneys

• Remember - you are not paid to practice Remember - you are not paid to practice defensive medicine or risk managementdefensive medicine or risk management

• Intervene with your clients according to their Intervene with your clients according to their problems, concerns, needs, personality, problems, concerns, needs, personality, situation, venue, environment and culturesituation, venue, environment and culture

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