Set 4 ground rules at the first office visit
Setting ground rules with patients at the first visit can prevent conflicts and strengthen your therapeutic alliance. Remember four “P’s”: punctuality, appointment policies, paperwork, and payment.
Starting and ending sessions on time gives patients a sense that they—and their time—matter. Patients can interpret late starts to mean that the previous patient was more important. For consistently late patients, starting on time lets you explain the importance of punctuality without hypocrisy. Effective time management also makes appointments predictable, which can reduce patients’ anxiety.
Be realistic about what can be accomplished at each visit. Tell patients before each session how much time is available. Allow time to write prescriptions, schedule follow-up appointments, sign consent forms, and document the visit.
Complicated patients—such as those with multiple psychiatric or medical comorbidities or an extensive medication regimen—may need additional sessions for psychoeducation and treatment planning after the initial evaluation. These extra sessions can cement the therapeutic relationship and reinforce treatment adherence.
Provide a written copy of your policy on missed appointments and discuss it with patients at the first visit. Post the policy prominently in the waiting area.
Schedule an additional appointment to write letters or complete paperwork that patients may require. Allowing patients to assist with the writing process improves accuracy and patient control over disclosure of sensitive information.
Address fee nonpayment early and often, as non-payment can have multiple dynamic meanings that can be explored during therapy. For instance, some patients may withhold payment to “punish” the therapist for what they perceive as ineffective treatment. Discussing nonpayment can increase patients’ insight into their behavior and help you decide whether to stop treatment.
Discussing financial matters in therapy can be awkward,1 but a comfortable discussion of payment policies can help some patients open up about sensitive matters later. It also subtly affirms your confidence in the treatment you provide.
Dr. Newman thanks the Clinical Scholars and Resident Research Track residents and faculty for their help with this article.
1. Geistwhite R. Inadequacy and indebtedness. J Psychother Pract Res 2000;9:142-8.
Dr. Newman is chief resident, child and adolescent psychiatry fellowship, University of Michigan, Ann Arbor.