The Pitfalls of Private Practice

Simon Milton, Professional Officer, HPCA

The Better Access to Mental Health Care initiative has dramatically expanded the availability of evidence-based psychological services. It has also led to an exponential increase in the number of psychologists working in private practice and, for the Psychology Council of NSW, a disturbing upsurge in the number of complaints. Many psychologists have had minimal or no supervised training in private practice and are committing basic errors to the detriment of themselves, the profession and their clients. Reviewing compliance with basic ethical responsibilities will be of value for all private practitioners.

In the first instance, psychologists should gain informed consent. Consent should be clearly documented in the client record, with copies of consent forms provided to the client. Consent should fully explain the psychological services to be provided and cover confidentiality, privacy and release of information. In private practice settings, any financial arrangements should be set out in advance, including cancellation and non-attendance fees, and the psychologist should make sure that these are fully understood. Financial arrangements should not adversely influence the services provided and the non-payment of fees should be managed promptly, respectfully and equitably with the client’s best interests as the priority.

Psychologists must practise within the limits of their competence, basing their services on the established knowledge of the discipline. Neither financial pressure nor the desire to appease referrers should influence the decision to take on or to continue to work with a client. Private practitioners need to be especially aware of whether they have the necessary knowledge and skill to assess, treat and manage complex presentations, as well as whether they are able to access appropriate resources. For example, a client with Somatic Symptom Disorder may require input from a multidisciplinary team including medical practitioners and physical health professionals. Taking on complex clients within the limited resources of a private practice may place the client’s wellbeing at risk.

Private practice can create significant challenges for maintaining appropriate boundaries with clients. Psychologists should refrain from entering into multiple relationships with clients where avoidable, being aware that using email, text and mobile phones to book and confirm appointments may lead clients to believe that psychological services will also be delivered by these means and that the psychologist will be available at any time. It is critical from the outset that clients understand when and by what means psychological services will be delivered. This is especially important when working with clients where managing boundaries is paramount.

Psychologists advertising their services should ensure that they comply with the Psychology Board’s Guidelines for advertising regulated health services, as well as the Board’s Social media policy. Advertising should not contain false and misleading information, nor should client testimonies be used. Psychologists should be particularly aware that many clients search online for information about their psychologists, often discovering personal information such as home addresses, political affiliations and relationship status. Psychologists should attempt to ensure that information discoverable online demonstrates professionalism and does not compromise any therapeutic relationship.

When a complaint is made against a practitioner, the client notes are a critical element for the Council in determining the facts of the case. However, when private practitioners are busy, record keeping can often fall below acceptable standards. Every episode of psychological service should be documented. In the Psychology Board’s November 2015 newsletter, Professor Grenyer offered the following:

Notes should communicate clearly what you did and why, giving clear reasons for various decisions and recommendations. What is written should be able to be justified on professional terms and give the reader a clear understanding of the rationale for what was done at that time. 'Skeleton notes', which only record the date and that a session occurred, are likely to be severely criticised by peers as not giving a satisfactory account of the service. 'Process notes' that reveal deeply intimate but irrelevant information about a clients’ personal circumstances are also likely to be severely criticised for potentially harming the client by breaching their confidentiality, privacy and dignity.

Psychologists are required to undertake a minimum of 10 hours of peer consultation per year. Private practitioners early in their career and/or working with complex presentations might consider engaging in regular and more formal supervision to enable a more systematic review of their clients. When Council investigates complaints involving complex presentations, the failure to seek timely and appropriate supervision is often noted.

Finally, private practice presents special challenges to a psychologist’s coping skills. Apart from the normal challenges of managing the emotional content of sessions, private practitioners often require skills in areas in which they have not been trained, such as practice management, supervision of non-clinical staff, and financial and taxation matters. Private practitioners can also take on more work than they feel comfortable with due to financial pressure. At these times, psychologists need to be aware that their self-care practices should form part of the psychologist’s regular routine. It is too late to employ self-care practices once you are ‘burnt out’. On investigation, it is often discovered that the poor practice that has led to a complaint is caused by a ‘burnt out’ psychologist whose judgement has been compromised.

There is little in the above that most registered psychologists do not already know. Yet the number and nature of complaints coming before the Council suggest that psychologists need to proactively manage the specific ethical challenges presented by private practice.