My colleague, Bonnie Goetz, MA, LPC, NCC wrote in on the Denver Therapists Network online discussion list asking for help . Having just had this conversation earlier this year in my Peer Consultation and Supervision Group, I asked her if I might address it here on my blog so that others can join the discussion.
Here’s what Bonnie wrote . . . .
I am wondering if anyone out there . . . has found a good way to offer the mandated 24/7 coverage other than being constantly strapped to a cell phone? I know some people use answering services, but from what I understand the service would call the therapist directly in case of emergency anyways.
I would really like to be able to turn off my cell phone at the end of the day, but have not been able to figure out a way to do this and still be in compliance with my [insurance] contracts. Generally I handle this by not taking clients who have high needs between sessions, but I still get the occasional call from people on the weekends or evenings, and I hate checking my phone all the time!
Any thoughts or suggestions would be greatly appreciated!”
Yep, I have a few thoughts and suggestions, Bonnie. Acts of omission, such as not returning phone calls in a timely manner, are definitely grounds for a malpractice suit. I’ve heard attorney Bart Bernstein, J.D., LMSW refer to this particular situation many times in his workshops on ethics and counseling. The example he gives is this . . . . If a client calls you and gets your answering service or, worse yet, gets an unanswered phone . . . and you as his therapist are the only person the client feels like he can talk to about a particular issue / crisis . . . and you fail to return the phone call in a timely manner i.e. within 24 hours . . . , you have, in effect, abandoned your client.
That’s why your question, Bonnie, is such an important one. Some therapists believe in error that being available 24 / 7 is stipulated by a particular managed care company. And, while that may be true, the bigger picture is that your professional associations, your licensing board, and your state laws are also likely to be requiring the same thing – that licensed mental health professionals must respond and be available to clients in a timely manner.
For those reasons, here’s a few of the ways that you can responsibly, ethically, and legally take care of your clients’ needs while also taking care of your own needs, too.
- Trade off with another trusted colleague.
- Use a professional answering service.
- Hire a virtual assistant or office manager to manage the initial contact with your callers.
- Consider using a paging system.
- Forward calls to another licensed mental health professional.
- Create a call group of licensed mental health professionals.
- Provide a code word for clients to use when they call in case of a crisis.
Or, you can choose to cover your own phone calls 24 / 7. Just remember that you are ultimately responsible for that coverage. If you have someone else covering for you, make sure that s/he is competent and trustworthy. Your clients’ lives, your own reputation, and your own licenses are on the line.
If you have found other ways to meet your clients’ needs 24 / 7, I hope you will take a moment to share with us here!
Ok – this got my attention. What about when I discuss my availability with clients during that initial session and have my county’s crisis line on my voice mail. Even if I return their calls within 24 hours, must I be their crisis line as well? What is one to do when physically ill and unable to return calls? Still abandonment?
I’ll be talking about this with my colleagues in private practice for sure. I know of one practitioner who states on voice mail that calls are not answered when not in office, but instead refers to crisis line. Still abandonment?
Beth, I so appreciate you taking time to parse out the details with me here. Again, I am not an attorney but it is my understanding that although we can say that we “don’t work with crises” and we can offer clients multiple ways to seek support in our absence, we are ultimately responsible for making sure that our clients have adequate mental health support at all times. That doesn’t mean that you can’t take off when you are sick or want a vacation. However, it does mean that you need to make sure that responsible mental health professionals who are competent and comparable to you in skill level are able, informed, and willing to cover in your absence.
Thank you for taking time to initiate this conversation with your colleagues in private practice. If in doubt, I would urge each of you to speak with at least one mental health attorney so that you are fully informed about your own rights and responsibilities concerning coverage of your practice when you are unable to do so. No one is expected to be physically present for their clients 24 /7; however, you are responsible for providing coverage in your absence.
Would love to hear from any of the mental health attorneys out there who are part of our community here at Private Practice from the Inside Out.
Hi Tamara!
Thanks for addressing my question on this forum. I am interested in hearing other folks’ thoughts on this issue as well. I want to make sure I understand your post; you are saying that as long as we respond to crisis calls WITHIN 24 HOURS (“a timely manner”), it would not be considered unethical/ abandonment? If so, that is much more lenient than I had supposed. When I held a contract with Medicaid while working in private practice in Colorado Springs, they mandated a return call with fifteen minutes, no matter what the time of day!
Thanks, Bonnie, for asking for clarification. No, I am definitely not saying that handling a crisis call within 24 hours is acceptable. It’s not. Clients need to have access to clinical support 24 hours / day every day of the week. If you can’t or choose not to be available 24 /7, then you need to find other professionals who can knowledgeably support your clients.
What is acceptable is to return non-urgent phone calls within 24 hours. And, in much of the business world, the expectation is that you will return phone calls within the hour.
I don’t know if that is different in different states. Here most therapists say on outgoing 24 hr msg phone: If you feel you are having a psychiatric emergency, please go to the nearest hospital/emergency room, or call 911. Do you think this meets the standards? If not would adding a pager do it?
Thanks,
ruth
Hi, Ruth! Thanks for dropping in here to chat. I think that many therapists, including me, have a similar message on their phone and that is fine. However, it is not sufficient to cover your legal and ethical obligations nor does it meet the standards of care for your client. You must be available or provide other competent professional coverage. Using a pager may be a terrific option to provide coverage . . . as long as you are responsive to the pages that come from your clients.
Great conversation! In the summer I go camping in the mountains and often have no cell phone reception for the weekend. I have had colleagues standing by in cases of emergency but not always. Luckily, most of my clients don’t go into crises mode too often, and so far, it has not been an issue on one of these weekend adventures. I will have to plan ahead better in the future and work with some colleagues to “monitor the phones.”
Hi, Barb! So glad to have you here!
I can so relate to your thinking but you need to remember that laws, ethical guidelines, and standards of practice aren’t usually put in place to protect “most” clients . . . . They are there to address that rare bird that teeters on the edge. I would encourage you to practice defensively . . . for your sake and that of your rare birds:).
This seems very curious to me, especially the 15mins. I am in session most of the day so I wouldn’t necessarily be able to return calls every 15 mins – not that I think there would be a crisis that often but… I will be consulting on this as well.
Hi, Holly! Thanks for dropping in to chat. I think that what Bonnie was addressing in her “15 minutes” was Medicaid’s expectation that you always have backup for your clients who are experiencing an emergency. I couldn’t support an emergency every 15 minutes either due to scheduling; however, I do provide emergency contact for clients and direction on where to go / who to speak with if / when I am not available.
When you say that you provide clients with a backup contact and where to go to get there, is this usually do during an informed consent/ intake session or do you provide this info on a voicemail when a client calls you in crisis
Hi, Alexis! I just noticed that you don’t have a little photo of you that shows up with your comments here (and on other blogs, too). They are called “gravatars.” Using a gravatar helps others get to know and trust you quicker.
Here’s a link to a quick tutorial that shows you how to set up your own gravatar http://www.allthingsprivatepractice.com/how-a-tiny-picture-of-you-can-help-drive-traffic-to-your-website-or-blog/ . (Don’t worry! It’s so easy that even I could do it and it’s absolutely FREE!)
Alexis, I think it’s important to do all of that:
~ Provide this info during during our initial meeting;
~ Provide this info in writing in my disclosure statement;
~ Remind clients of this as needed during our sessions; and,
~ Leave emergency contact info with the answering service or or on voice mail when you are not available.
When I go out of town, I typically leave a voice mail message that says “I’m not available to take your call right now.
The office is currently closed and will re-open again on such-and-such date. If this is an emergency, please hang up and dial 911 or go to your nearest emergency room . . . .”
Or, if I’m away for a lengthy period of time, the message will say “If this is an emergency, you may reach my colleague Licensed Professional Counselor Jane Doe at this number . . . . “
Hi, Tamara –
I’m confused now… This answer to Alexis seems to say that the therapist can go out of town and refer calls to 911 or a hospital Emergency Department. But it was previously stated to Ruth that “it is not sufficient to cover your legal and ethical obligations nor does it meet the standards of care for your client. You must be available or provide other competent professional coverage.” So… which is correct? And does this vary by state?
Also, to follow up on the end of this reply to Alexis, you note that if you’re away “for a lengthy period of time” you will refer to a specific colleague. What qualifies as “lengthy”?
I do realize you’re not an attorney and I appreciate you putting this conversation on the table. As these are legal, as well as ethical, issues, it may behoove us all to check our state Administrative Codes.
Hi, Lisa! Thanks for dropping in!
I’m so sorry this was confusing.
If you are a therapist in private practice in the United States, it is a best practice to provide resources for emergency situations that callers can reach and access quickly i.e. ” . . . Call 911 or the local emergency room at . . . .”
However, it is not a sufficient practice by ethical, legal, and most community standards of practice for you to leave a recorded message like the one above with no additional resources for clients in crisis.
Instead, you will need to arrange for other mental health professionals whose training / experience is deemed competent and professional in your local jurisdiction to cover those emergencies.
And, finally, “lengthy” is something that is best defined by the standards of care in your own community, your professional discipline’s code of ethics, your Licensing Board’s Rules for practice, and your state Statutes.
In the geographic areas that I have practiced, the length of time permissible for a Professional Counselor to be out of range of contact has varied from 1 hour up to 24 hours.
Here in Colorado, I attempt to return all phone calls the same day that they are retrieved; at the very minimum, I retrieve and return messages within 1 business day.
I will add that new professionals often struggle with needing to identify and abide by “standards of care in your own community” because, of course, they are not written down anywhere.
If this is your situation, I would encourage you to poll a large number of clinicians in your own town or join a local professional association to access their understanding of community standards related to this particular issue.
You are right, Lisa, that I am not an attorney, not able to provide legal advice, and do understand that laws, codes of ethics for individual disciplines, credentialing boards, and standards of practice do vary from jurisdiction to jurisdiction.
One of the most unnerving things I had to do as a new professional was to realize how much of our work really is about making judgment calls all day long every day.
Most of the work that we do falls into “the gray” rather than the black and white thinking I was raised with.
Hi Tamara,
What about individuals who are not clients, calling and leaving messages on voicemail (outgoing message states dates office closed), while you’re on vacation. Do return tgeir call within 24 hours or adhere to boundaries and call upon your return from vacation?
Hi! I am just getting started in private practice and am checking into what to do to have other avenues for clients when you are not available. I live on a mountain and do not have cellular service available at times (depends on the weather, and other various things– all cell phone calls drop at some point when I am at home.) GPS also does not work at my house. I am looking for other avenues that I can connect with to have backup in that instance. Any other suggestions would be great. I don’t have any other coworkers in my area that I can refer to at this point, so I am looking more into having a service, though they would likely not be able to reach my house either. Thanks much–
Thank you for that informative article! I have a question – in your opinion do you think it is sufficient to provide phone numbers to hotlines that are available 24/7 with licensed professionals?
I am new to private practice and I’m trying to maneuver everything.
Thank you!
Hi, Brittany! Love that you asked this question!
The response I have heard from attorneys has consistently been “No, it is not sufficient” although I suppose that answer could vary from state to state.
However, the reason I have been given is that you cannot guarantee that the hotlines are still functioning, are adequately staffed, etc.
And, of course, you are handing off your clients to an organization of people who you have no personal knowledge or relationship with – and they have no knowledge of your most fragile clients.
Best wishes to you, Brittany in your new practice! I hope you will be back here to chat often!