In my blog for my Johns Hopkins graduate students, I received an email from a clinician asking about how to manage what they referred to as the “business aspects” of their practice. By this they meant, setting up appointments, handling the ending of a therapy session, establishing and collecting fees, handling of cancellations and, “no shows”, dealing with insurance companies, consents to share information and related fare. I’ll be addressing these and related issues in this blog in the weeks to come.

Although I agree with the clinician that there is certainly a business component to these decisions, I believe that decisions regarding the frame have far reaching therapeutic implications. Moreover, in setting policy, I feel that the clinician must consider every aspect of the frame with special care. Typically, in working with patients, we encourage them to speak openly and without fear of reprisal. The session is for and about the patient and we do our very best to set aside our personal agenda and to listen in a non-judgemental fashion. The so called, “business” aspects, or as they are referred to in clinical parlance, “the therapeutic frame” are first and foremost about the clinical needs of the patient. However, they also reflect the clinician’s needs. Clinicians are typically earning a living and therefore, expect to be paid, expect others to agree to and adhere to a schedule, etc. Thus, these aspects of practice are very important because they convey much to the patient about the therapist’s method of working. Deviations and departures from the frame, whether by the patient or the clinician, warrant careful attention.

For those beginning a practice, establishing a frame can be especially challenging. The clinician is eager to have patients. This can make the clinician ripe for patient attempts to tinker with the frame. For example, many patients, though not all, might prefer to come for free or might prefer to drop in any time without scheduling. Some would prefer to have longer sessions and others might prefer shorter sessions. Some would like to schedule appointments and to show up only if they, “feel like it”. The new private practitioner, even though he may be an experienced clinician, is vulnerable to patient efforts to tamper with the frame. Unfortunately, failure to be thoughtful about allowing alterations in the frame is likely to compromise the treatment. It is for this reason, that we will consider aspects of the frame.

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