When the Client’s in Charge

by Lynn Grodzki, LCSW, MCC

Private Practice Success Newsletter, December 2010

____________________________________________________________________________

Given our uncertain economy, those who own and operate a private practice have some important choices to make about their future.

I wrote about this in an earlier newsletter published in September 2010. (You can read the article:  “Forks in the Road” by clicking here.  In this article, I likened your situation to walking down a path, coming to a fork in the road, and having to choose one direction.

To stay viable, effective, and profitable, I believe that therapists in private practice will operate their practices within one of these three business models.

Deciding which one is best for you depends on may things, including your philosophy of service, your training, and your values. All three models seem to work well today and in the future, but to stay successful, each requires a different approach or “positioning” for the therapist and the practice.

No matter whether you are in a solo private practice or a group practice, chances are you are already headed down a path towards one of these models, but you may not be conscious of it yet.

It’s time to wake up and plan.

A Wake-up Call

In my earlier email newsletter, I explained that the future of your private practice will rest on adopting one of these 3 business models which I term:

•    The Consumer-Driven Practice
•    The Insurance-Driven Practice
•    The Theory-  or Belief-Driven Practice

This month I will explain the consumer-driven practice, so you know how to adopt this approach both clinically and from a business perspective.

Ready to learn more? This model follows the old maxim: the customer is always right.

The Consumer-Driven Practice

First, let’s put this in perspective:

Forty years ago, therapists began to move away from the medical model of practice. A medical model suggests that the focus is on pathology or illness, diagnosis, treatment, cure, with the therapist in the role of a doctor.

In the medical model, therapists were seen as doctors; referrals came through other professionals; few therapists advertised, marketed, or reached out to the public directly.

But as more varied professions became licensed to offer counseling and psychotherapy, a broader approach followed, and the medical model was replaced by holistic, alternative, social, or recovery models of treatment.

Patients were now clients; pathology was now behavior. Therapists reached out to the public to promote their services and the hierarchy between therapist and client shifted dramatically.

Today, it’s common for clients (also known as consumers) to sit in the driver seat of their own therapy, to feel more in control of the outcome of their treatment.

The best description of this shift in control and outcome is within the research and writing of Barry Duncan and Scott Miller, whose many books explain the rationale and importance for using a feedback-directed, outcome-focused approach.

The Next Step

In an online interview with David Van Nuys, Miller explains this practice model:

“We have known for years, at least 40, that the relationship between the client, the consumer, and the provider of care is predictive of outcome. We also now know that if consumers are asked, and able to provide feedback about the nature of the [therapeutic] alliance, positive and negative, that those consumers are much more likely to stay until they achieve a good outcome in treatment and we have better outcomes as a result.”

(Read an online interview with Miller here or see more about Miller’s work and website here)

Client Feedback First

Miller encourages therapists to stay in a feedback loop with clients by using a simple measurement scale, filled out by the client, at the end of each session. The four aspects of the scale that clients rate are:

•    Relationship with the therapist
•    Goals and outcomes discussed in the session
•    Approach or method therapist is using
•    Overall impressions

If a client scores the therapist poorly in any area, in any session, this is immediately addressed by the therapist with the client, to improve the alliance each week.

Reliance on Alliance

As Miller explains, “Listening and responding to clients is the relationship. That’s the beauty of what we are proposing: all we have done is formalize that process, provide a formal structure.”

To make this approach, work, Miller stresses that it is important that therapists stay flexible in their approach with clients, non-defensive, and willing to alter the service until the client says they are satisfied.

How it Works

OK, now I want to show you how this works in real life with an interview from a therapist who has built a successful practice by walking down this path.

Last month, I spoke with psychologist Eric Kuelker, who uses this feedback process with every client and mentions it to all his referral sources.

Eric lives and works in Kelowna, British Columbia, and built a full-time private practice, after a career in hospital and university settings. He relies on Miller and Duncan’s feedback measures to be successful with his clients and to promote his practice to others.

Based on his good experience with this approach, he created an internet portal for therapists that sells access to the same software he uses to measure client outcomes. It also hosts a number of interesting resources for clients that Kuelker says heightens client alliance. (See his portal at: http://mentalhealthpros.com)

Building Referrals

Eric attributes his success in building referrals with physicians, in large part, based on his data. He tracks the rating scale from each client after each session. Using his software on a laptop, he turns the ratings into easy-to-understand graphs of client satisfaction and outcomes. Eric says that physicians are his primary referral sources, because of this evidence-based approach.

“When I meet a new physician, I show him a quick power point presentation explaining what I do, how I get feedback from clients, and how the measures improve the relationship I have with each client and the outcomes they achieve.

“A critical part of the power point presentation to the docs is the research on how measuring outcomes and alliance doubles the effectiveness of psychotherapy.  Their eyes literally pop open when they see the graph on the quadrupling of happiness in marriage therapy when a therapist measures, compared to when they do not.

“Doctors tell me is highly unique is that they never get follow-up letters from psychologists, and they never get objective data back from them.  This is the issue they comment on.  The follow-up letters and graphs I send them really convey that I do evidence-based health care.

“I show them that data about my practice as well. I average 5 sessions per client, with the biggest shifts in a client occurring in the early sessions. I can show them types of presenting issues and chart the rate of resolution. They are fascinated to see my actual results.

“I think this gives me the ability to charge my full fee (instead of a discounted insurance or EAP rate) because I can show doctors that my clients get value for their fees. I also explain that the fees cover a range of client resources (on my internet portal), such as client journaling – so my clients get big changes on the issues that are important to them and need 30% fewer sessions than if they went elsewhere,” Eric adds.

How do his clients respond to being asked to measure each session?

“My clients like seeing their graphs. At the end of every session, they use my laptop to fill out their rating. We discuss it right then. If there is a bad rating, they tell me why and I correct the problem. I am flexible. Even when we have been working for a long time, I still want to know how they feel about each session to keep us on track. This is my way to insure an effective therapeutic alliance,” Eric concludes.

Making This Work for You

If this is your path or business model, you need to actively solicit feedback from clients about your sessions, and let the clients drive the session. My suggestions include:

1. You need to stay flexible in your approach and non-defensive about the feedback. When clients have suggestions or additions, correct quickly.
2. Use  measures post session and track the data. Eventually, you can use your results when talking with referrals sources or on your website, which is a very consumer-friendly approach.
3. With your internal data, your practice may be one of the few able to promote such statements as: “90% of my clients say that they felt heard and comfortable with the first session.” Or “8 out of 10 clients completed their work in 6 sessions with full satisfaction.”

Stay tuned: Next time, I explore yet another business model.

Share This Page With Friends and Colleagues