Practical Questions Beginning Psychotherapy

When making a referral, a common practice is to give patients three names, so that they can interview each and make their own selection. I do not agree with this approach. I do not know how a patient can make a rational decision about which of three therapists will ultimately be best on the basis of one or two interviews.

With the above in mind, I prefer to give only one name. I tell the patient that, although I think that the therapist selected should work out, if there are any problems, to please call me. Before referring, I discuss with the patient the type of therapist desired, finances, geographical location and any other relevant issues. With that information in mind, I select a therapist whom I think will work. Additionally, I find out if the therapist has hours available that are suitable for the patient and is willing to see the referred individual. If the patient is dissatisfied with this referral, I am then willing to discuss the relevant details, making another referral when appropriate. One name, given in this manner, works out the vast majority of the times. If, however, the patient is insistent on getting three names, I go ahead and give them.

Arrangements that need to be discussed early on include scheduling of appointments, payments, handling of missed appointments, guidelines for the patient and, on occasion, expectations regarding interactions outside the sessions. Scheduling appointments convenient to both patient and therapist is, of course, ideal. Payment arrangements that need to be addressed include both fee and collection policy. Many therapists have some flexibility in their fees, with some ability to make adjustments in accordance with the patient's income. In these situations, frank discussion of the patient's finances and insurance coverage need to be part of the fee-setting. It is important that both therapist and patient are comfortable with the fee.

A usual practice is to bill at the end of the month and collect shortly thereafter. Payment can be due the session after the bill, two weeks later or a month later. Sometimes there is an agreement to wait until the patient has collected from insurance. Whatever the arrangements, they need to be clearly agreed upon. Deviations from the agreement then can be focused on in the treatment hours, as they occur. Charging for missed sessions, guidelines for the patient, and interactions between therapist and patient outside the sessions will be discussed in the final three questions.

Some patients enter treatment with some urgency, in some state of crisis or regression. They are preoccupied with their problems, and want to address them as soon as possible. For these patients, discussion of the above arrangements can be burdensome, seeming like a distraction. For patients in this category, I discuss the arrangements piecemeal, after some of the presenting issues have been addressed, and when the patient is in a calmer state. The patient is then able to approach the arrangements both with more interest and more cooperation.

Not long ago, the usual rule regarding missed appointments was for the therapist to charge unless the time was filled. A reasonable addition to this was that, given advance notice, the therapist was willing to reschedule, if possible. Although still reasonable in many cases, this rule appears to be going out of favor. Some therapists have a rather liberal policy of not charging if notice is given a certain number of hours in advance (like 24 or 72). Others do not charge if there is a good reason for the missed appointment. The latter is never a good idea. Illness, car problems, college examinations or other important appointments, although reasonable on the surface, are often used as resistance. Evaluation of the reasons for missing appointments puts the therapist in the unwanted position of an authority figure, inviting the patient to rebel.

The therapist can show some flexibility in establishing agreements regarding missed sessions. I favor telling the patient that my usual policy is to charge for missed sessions unless I fill the time. An exception is that I am willing to reschedule hours, if possible, when given advance notice. I state that I understand many have difficulty with such a policy. Thus, if the patient has any misgivings, I am willing to discuss them.

I do believe that the policy as stated is beyond the usual experience of many. Some patients see it as overly rigid, greedy, one-sided and unfair. With those who are not able to understand it from the therapist's perspective, the policy is not a good one. In these cases, modifications are necessary. With some patients, where I sense that there will be clear antipathy toward the usual policy, I do not bring it up. If and when a problem arises with these patients, I approach it in a flexible manner.

It is useful for the patient to be given a set of guidelines regarding psychotherapy near the initiation of treatment. These guidelines establish a frame for the therapy, one that can be returned to whenever there is a deviation. A standard presentation that is useful for most patients is as follows:

Therapist: These sessions are yours, to talk about anything you want. It will be up to you to choose the topics. Often there will be topics that are on your mind that you very much want to talk about. At other times, this will be less clear. At times when you do not have topics of pressing importance, it is helpful to talk freely about anything that comes to mind. In fact, whenever you have extraneous thoughts or fantasies, it is useful to talk about them. There are certain thoughts that some people find difficult to talk about and are tempted to omit. I want to urge you to do your best not to omit those types of thoughts. These include thoughts that cause uncomfortable feelings, such as anxiety, anger, embarrassment or shame; ones that you view as silly or irrelevant; ones that you are fearful that I will disapprove of; and any thoughts, positive or negative, that refer to the therapy or to me personally.

Regarding interactions between patient and therapist outside the therapy hours, the general rule is the less, the better. The therapist can make it clear that calls at times of true emergency are welcome and even expected; otherwise phone calls are not desired. Emergencies necessitating calls sometimes need to be spelled out; many so-called emergencies can be easily handled without the therapist. The generalization here is that psychotherapy proceeds best when it is confined to the therapy sessions. If there is not enough time during the sessions, the frequency of the sessions can be increased.

Of course, there are numerous exceptions. Some patients, for example, need very brief occasional contact to confirm the reality of the therapist. Others need various kinds of brief contact to avoid overwhelming anxiety. Under these circumstances, therapist and patient can arrange for limited telephone conversations.

Specific agreements regarding phone calls need not come up at the beginning of treatment, unless an obvious problem is anticipated. Discussion can wait until after the first or even second call. At that time, the rationale for any limits can be stated and discussed. Limits set in a reasonable way can make the difference between virtually no phone calls or daily phone calls. To set these limits well, the therapist needs to have good boundaries regarding the therapy hours, plus the belief that therapy is best carried out when it is confined to well-defined sessions.