Many of us spend considerable time learning the ins and outs of ethical behavior in clinical practice. In starting a private practice, a business, there are business ethics, however, they vary more widely. There are laws in place to govern businesses, and codes of ethics to guide our business behavior as therapists as well.
And yet, there are is a lot of discussion about what is ethical and ok in private practice marketing. Within that discussion there is also a lot of disagreement. Here are just a few discussions we have heard out in the private practice world.
It is unethical not to accept insurance.
It is unethical not to offer sliding scale to everyone who calls you.
It is unethical to charge a certain fee.
It is unethical to hire contractors to work within your private practice- no matter the situation.
It is unethical to refer a colleague to any other business if that business offers any sort of thank you, or perk, for that referral.
It is unethical to offer coaching if you are a licensed or unlicensed therapist.
It is unethical to start to market or brand yourself prior to licensure.
Let's dig into each of these and explore the ethical concerns that are raised within each. I'll share my take on each- but realize codes of ethics vary from organization to organization, from state to state, and the most important ethical standard? The one you carry internally within you!
1. It is unethical not to accept insurance.
Choosing whether to accept insurance is a business decision, it is not an ethical one. While we want to as humans and great therapists ensure that mental health services are easily and widely available- accepting insurance is just one possible avenue to making that happen.
Another avenue to ensuring equal access is to support a local non-profit with proceeds from your profitable private practice, donate supervision time, provide reduced fee supervision, or include pro-bono slots in your private practice.
2. It is unethical not to offer sliding scale to everyone who calls you.
Many therapists learn their business practices working within non-profit environments. Non-profits often operate from funds provided by government grants or foundation support. The sliding scale that they collect is often not sufficient to function. They may also have someone who looks over tax returns or pay-stubs to determine fees. As a therapist in private practice- you may not want to be digging into that sort of detail. Read more about sliding scale in private practice here.
3. It is unethical to charge a certain fee.
I've heard from more therapists than I can count- that their ethics and integrity have been questioned based on their fees. Laws and regulations have been set to ensure that there is not unfair fee setting. The rules have been built to make sure that a group of service providers don't get together and make a pact to raise prices. This would prevent unhealthy competition, and be unfair to consumers.
This isn't an issue for therapists. Therapists feel pressure to keep their fees at a particular place- sometimes a really low level- but they often have no idea why. They have not calculated their expenses, developed a business plan, projected their quarterly taxes, or developed a plan for ensuring they can stay top of their game by receiving great training or clinical consultation.
The fee you personally charge is a private decision based on your unique situation, expenses, the make-up of your family, your financial goals, the cost of living in your area, etc. It is not something your colleague down the street, or someone online should determine.
A great example, I have a colleague who is an awesome eating disorder specialist in Oakland, CA named Signe Darpinian. I was helping her transition to a paperless office and asked her fee so I could key it into the system. As she told me her fee she winced and said "is that ok?" She then started telling me about the time she spent outside of session consulting with Stanford, the time spent getting top-tier training, the emergency calls, etc.
Why did she wince? She has gotten looks, questions, and blow-back from other therapists about her fee. Even though Signe was confident about her fee, knew her value, knew how much she had invested in her training, knew she did great pro-bono work, etc,- she didn't know how I would respond!
4. It is unethical to hire contractors to work within your private practice- no matter the situation.
Employment and contract law are very complex. It is illegal to hire an employee, and pay them as a contractor. You need to understand the specific differences between contractors and employees, know your particular process, and choose the option that is the best business and clinical decision. Generally, if you are unsure if someone is an employee or a contractor after reading the IRS description- they are probably an employee. These are areas where you can seek consultation with a specialist in this area to understand the law. However, there are some circumstances where a lawyer will explore your situation and advice that hiring someone as a contractor is appropriate. It is a legal situation, not an ethical one.
5. It is unethical to refer a colleague to any other business if that business offers any sort of thank-you or perk for that referral.
It is unethical to pay other therapists or individuals for referrals to your clinical work. You need to be careful even with gift giving as it can be construed as a referral fee. In other businesses- referring to a massage therapist, sharing your the name of your attorney, or introducing someone to your carpet cleaner- a referral fee or gift isn't uncommon.
Why is it unethical in private practice? The fear is that people will refer to subpar therapists because of the fee or gift, not because they believe they are providing exemplary services. The truth is, most of us are not privy to how someone is in the room- which is quite different from a referral to a service provider you personally were able to experience.
So, what do you do to avoid any issues in making great, unethical referrals? First, you only ever refer to something you really believe in. I don't care if someone is willing to give you a new car- you absolutely never refer to something you don't think is awesome. If you refer a client to a service provider and that person offers a referral bonus of some kind- politely decline to avoid any appearance of impropriety or benefiting from your clinical relationship with a client.
If you refer a colleague, friend, or family member to something you think is groovy and someone offers you a bonus, fee, or gift- check your motivations. Did you make the referral based on a true belief that this was helpful? Enjoy the gift! Did you make an inappropriate referral to something you didn't believe in for personal gain? Decline it. Your integrity is more important than any amount of money.
6. It is unethical to offer coaching if you are a licensed or unlicensed therapist.
Unfortunately, we are seeing more and more people hearing that offering coaching is a way to circumvent the licensure process. Psychotherapy is a clearly regulated field in most states and countries. Simply providing psychotherapy and calling it coaching, consulting, etc. is not ethical.
However, not everyone needs, requires, or wants psychotherapy. As an educated, experienced professional you may offer services that are not regulated by law. That includes workshops, training, consultation, and coaching. Most therapists are not clear on exactly what their license actually covers. Look up the laws and regulations in your state or country so that you truly understand what you can provide.
When you are marketing a service outside of psychotherapy, you may not want to include your professional designation at all- to avoid potential clients getting confused about your scope of practice.
Even in California, if you are pre-licensed therapist- you can own your own business. You just can't practice psychotherapy in your own business. In fact, you could own a business where you hired licensed therapists to provide psychotherapy, and market that practice, you just couldn't actually provide psychotherapy within the business you owned.
7. It is unethical to start to market or brand yourself prior to licensure or before you launch a private practice
It is absolutely unethical step outside of the laws that govern marketing in your state. However, many therapists who are planning to launch a business are getting more savvy about steps they can take weeks, months, or even years in advance.
One of the most frustrating thing that therapists encounter when launching a new practice is with getting new clients. Why? Because often this is the last detail that therapists consider. We spend hours on NPI Numbers, informed consent forms, the look and feel of our office... but how to actually get clients is often last on the list.
There is nothing that says you can't market or brand you today- even if you aren't in private practice yet- or aren't licensed. You can start to build your online resume, and become findable for the keywords you think future clients would type into Google. It can take several months to get to the first page of Google (longer if there is a lot of competition)- why not start now by providing some great content to your local community.
How did I become known? I got really fired up about something I was passionate about- supporting pre-licensed therapists in California and started a blog. I didn't plan on, or know that, it would lead to future income or a professional reputation. I just truly wanted to help other people like me who were stumbling through the process of licensure. MFTGuide.com now helps over 1000 therapists a month. People around the country type in really specific questions about the licensure process for MFTs- and they get articles that help and support them! How cool is that?
I started my free online study group and the marketing process before I was licensed. I started the blog as a newly licensed person before I started my private practice, and well before ZynnyMe was born. The truth is, therapists are not the most lucrative business owners to work with. I've worked very successfully with other professions- so they therapists?
Because I love this profession. I love therapists. I love this work. I'm meant to be doing it.
So, what can you do today to explore your own ethics in the business side of your private practice? Here are some steps to take:
#1. Download the code of ethics from the professional organization that you belong to. If you belong to more than one, download all of them. When you join a professional organization, you agree to be bound by their code of ethics. I've actually had to decline joining certain professional organizations because I felt their code of ethics bumped up against my legal responsibilities as a MFT in California.
#2. Read the code of ethics. Bring two highlighters. One to highlight things that you want to look further into from a clinical perspective, the second color to highlight anything related to business or marketing.
#3. Write down your questions, concerns, ideas that come up and relate to your clinical practice or the business side of your current or future private practice.
#4. Get your questions answered! Reach out for a consult to your professional organization if they provide that as a service. Or, contact local professionals who have experience in these areas to discuss these issues in professional consultation. Write down questions that come up, look up any applicable laws.
#5. Document what you learned and how you will ensure you are following these ethics in writing somewhere. You can e-mail your notes, who you spoke to, copies of the ethical codes, legal codes, etc. to yourself so if anyone ever asks how you made your ethical determinations- it is there in writing!
Post your questions about business ethics in private practice below!