Interviews with Jennifer Hollinshead, RCC-ACS, founder of Peak Resilience, and Carolynn Turner, RCC-ACS, and founder of Lavender Counselling
While Standards of Clinical Practice provide guidance on many aspects of being a counsellor in B.C., private practice RCCs need to make their own decisions about a few areas, for example, complimentary sessions, sliding scale, no-shows, and cancellations. A primary reason BCACC doesn’t have rules for policies like these is to ensure the counsellor has enough autonomy to allow the therapeutic relationship between the counsellor and client to remain the priority.
As Jennifer Hollinshead, RCC-ACS and founder of Peak Resilience, points out, studies have shown — and most counsellors would agree — that the therapeutic relationship is the biggest predictor for success in therapy, no matter how the client may define success.
“If we’re all coming back to the relationship being the most important predictor of therapy working, we also need to have boundaries, and we need to recognize that therapists are 50 per cent of the relationship,” she says. “Every therapist is their own human being in their own location, dealing with their own privileges and barriers. The policies they create need to reflect what is sustainable practice for them and what is also trauma-informed and realistic for clients.”
But how do you create your own policies? You start by turning inward, which counsellors are seldom taught to do.
“We are really, really good at turning outward and asking what the client needs and what a situation requires,” says Carolynn Turner, RCC-ACS and founder and director of Lavender Counselling. “But part of our job is honouring the relationship. Does it feel clean in my heart to provide pro bono counselling, or sliding scale, or complimentary consultation?”
That turning inward is your responsibility to yourself, your client, and the therapeutic relationship.
“If I don’t first listen to myself, and I’m building resentment or a sense of frustration, then I’m going to bring that out in the relationship with the client,” she says.
Further, decisions about these policies may require flexibility at different times in our lives.
“When my children were young, I actually couldn’t be very flexible in offering last-minute sessions to clients,” says Turner, explaining that childcare arrangements meant sticking to her schedule. “Referring clients out to community supports because of this sometimes felt really sad for me.”
It was through processing her own sadness and setting the boundary that came from that process — “I wish I could help, but I can’t. I have my own family.” — that Turner was able to prevent a lack of agency and subsequently a sense of burnout. Doing the work in a way she feels proud of helps to ensure she doesn’t become bogged down.
Now that her children are grown, she may occasionally let a client know they can reach out for a last-minute session if something urgent comes up. She also does more pro bono work now than she did when she was new to the profession, and she may sometimes offer a sliding scale.
“To go back to that expression ‘clean in my heart,’ I feel great about it, because as much as my motivation for helping has always been there, my financial stability has changed, so I have more space to do that,” she says.
As BCACC Approved Clinical Supervisors, both Turner and Hollinshead offer their perspectives on policies every private practice RCC needs to consider.
Complimentary consultations
Turner is passionate about complimentary consultations — 20 minute conversations intended to allow the client to explore whether the counsellor is a good fit for them.
“Our whole business offers a complimentary consultation, and I intend to do this for the rest of my career,” she says. “For me, it’s about giving trauma-informed principles their space in every facet of my business. If we think about empowerment and trust and safety, and we know the relationship contributes to so much of the therapeutic outcomes, then I believe it’s the client’s right to experience me without having anything negative, including a financial transaction, taken from them.”
Turner adds that they offer clients a consultation only (20 minutes) or a consultation and half session, which they pro-rate to accommodate for the consultation.
“Some clients want to get right into things,” says Turner. “Some clients want to try all of our counsellors to ensure they find a counsellor who is just the right fit for them.”
Turner treats the complimentary conversation as a mini session.
“We go through consent and what has brought the client to counselling and, ultimately, we explore how we, as the counsellors, might support them in that struggle,” she says, noting that they take client information and their signature on consent documents in the same way they would for new client coming for full sessions. “This is part of the ongoing process of informed consent. If the client is choosing to share information with us, they have the right to know what we could potentially do with it and they have the right to choose if they wish to share with us based on that.”
But providing complimentary sessions also needs to be right for the counsellor.
“When it’s not aligned for a counsellor — maybe they’re doing it because they feel they have to or to drum up business when they’re new — then what ends up happening is they compromise themselves in those consults,” she says. “They do them while they’re busy or otherwise occupied and then they’re just trying to fit them in on the side. This can compromise the whole process. If the counsellor is not doing a complimentary session in a way they feel proud of, then they can end up resentful or frustrated about it and that can come up in the therapeutic relationship in tricky or unhelpful ways.”
Counsellors need to be honest with themselves about how they feel about complimentary sessions. Can they afford them? Do they value them? Can they prioritize them? If the answer is no, then it’s important not to do it.
Hollinshead points out that it is important to distinguish between complimentary sessions, which would be 50 minutes, versus consultations, which are usually 10 to 30 minutes.
“If we can provide a very small consult about the therapeutic work we might do, but this is very different than a first full session,” she says. “Once I provide a first session with someone, I’ve gotten them to sign informed consent and we’ve usually gone into enough of their history to create a starting treatment plan.”
And while pre-session free phone consultations are available at Peak Resilience, only 10 to 20 per cent of clients take them up on it, because they get so much information ahead of time to reduce the need or desire for a complimentary session. The information includes introduction videos as well as an in-depth email. The client also provides information on a pre-session form with a series of questions to determine the best counsellor match.
“We know people are oftentimes coming in with the most unthinkable, scary, traumatic, nerve wracking, emotionally heavy things you can even try to think of,” she says. “I find as a practitioner and as a client, I really appreciate the ability to get to know someone before booking because sometimes it’s not the best fit. We have both saved ourselves time, energy, and potentially hurt feelings.”
Sliding scale
Hollinshead laughs when she says the more than 6,000 RCCs in B.C. probably all have different opinions on sliding scale — and that may be.
“My philosophy is that there are people in our community who have a lot more access to resources than others,” she says. “We have adjusted our regular rate to allow us to offer a sliding scale. This means, essentially, that our regular rate is $5 to $10 higher than we could have it if we didn’t offer sliding scale.”
Hollinshead adds that people who are paying the regular rate know some of that money goes towards people who are getting a sliding scale. She even wrote an article about where the money for a counselling session goes. *
While paying it forward is the philosophy at Peak Resilience, other RCCs can say no to sliding scale if that is what is best for them — it is their choice.
At Lavender Counselling, each therapist chooses how they navigate sliding scale rates; however, instead of having a certain number of sliding scale spaces, most of their RCC offer time-limited support to current clients who are financially struggling and wish to continue counselling.
“If someone is looking for ongoing reduced-rate support, we offer sessions with one of our student interns,” says Turner. “Clients can access up to eight months of weekly reduced-rate sessions with the same student therapist. If they wish to continue to access reduced rate services, they can move to working with another student when their current student has completed their placement. This allows RCCs to have a safe place where they can refer sliding scale clients.”
*Counselling + Where your money goes. https://www.peak-resilience.com/blog/counselling-where-your-money-goes.html
No-shows and cancellations
Turner has a firm policy on no shows and cancellations, again, as a result of turning inward and setting boundaries to prevent counsellor resentment and frustration that may affect the therapeutic relationship. It is a policy aimed at preventing unspoken expectations that may derail clinical work.
“When the client books, there’s an immediate reminder email that says we honour our cancellation policy,” she says, adding that the policy is also included in a 48-hour reminder email, as well as in the consent documents she goes over with every client. “And our expectation is that we are paid for our services, that we deserve to be paid, and as such, we ask clients to provide a credit card number so that if they don’t pay, we can charge it. We want clients to know that’s our expectation and we are direct about it.”
In fact, Turner has one client* who, due to an illness that prevents them from being stable, is a no-show for about half their sessions.
“Everywhere else in their world, they’re shamed for that. People are disappointed in them. They’re frustrated. They’re hurt, and they have expectations of the client, and the client has really developed this internal sense of shame as a result,” says Turner. “The greatest gift to their healing I can give them is actually to accept their no-show with grace, with genuine, unconditional, positive regard, and the only way that I can do that is by saying, ‘I’m going to charge you, while at the same time accepting you fully.’”
An authentic, direct policy with no hidden agenda gives the client space and frees them from shame. It also frees the counsellor from carrying something that prevents them from being congruent in the therapeutic relationship.
*Information based on a composite client who is an amalgamation of clinical experiences to protect their privacy.
Refunds
How to handle requests for refunds is another decision each RCC needs to make for themselves. Turner admits her experience with refunds is minimal — once because of a technological glitch — but she does offer an enlightened perspective. Her inclination is to rebook a complimentary session and discuss what the client was hoping for in the first session.
“So often, what happens in the therapy room is a microcosm of the client’s life, and if they’re engaging in this way with us, it’s quite possible this is part of their struggle in the world,” she says. “But I would meet with them complimentary and see if I can make some identification of how this may show up in their life on other occasions. It might be helpful to them. And they still may decide they don’t like me and don’t ever wish to come back, but my hope would be that I could leave them with something that mattered.”
Rate increases
Rate increases are a loaded topic, says Hollinshead, but it comes down to creating your practice and knowing your expenses, which dictate your price model.
“We do a very gradual price increase of two to five per cent per year as needed based on operational costs, not profit,” she says.
And you need to be at ease with raising your prices or risk getting stuck in defensiveness.
“Often, we deny ourselves until we’re bursting at the seams,” says Turner.
When that happens, communicating that increase may come out clunky or harshly, she says, adding that if counsellors are not settled in themselves about a price increase, they may drag their feet in communicating it to clients and risk leaving clients feeling they are not being respected.
“If we really do the work around being okay to ask for a price increase, then we go to our clients from a different space — one where we have lots of space to hear how hard this makes life for them. I don’t have to fix it and I don’t have to defend it,” she says. “I can just be with them in that and wish alongside them that it were different, and really, that’s compassion in action.”
Each year, Turner reviews and often rewrites her consent document and that includes re-stating or changing her rates, if necessary. Then if there are changes, she goes through the revised consent document with her existing clients.
“I try to think about what it would be like to be in the client’s shoes receiving a price increase or a new communication,” she says. “I always make space to process that in therapy.”
She encourages lots of notice around rate increases — especially now with interest rates rising and many clients financially struggling. I try to give three-plus months of notice.
“The more notice, and the more different ways we can give notice, is really important because if we think about trauma-informed care, safety and stabilization are essential,” says Turner. “As is doing what we say we’re going do and being trustworthy. Our words and actions have to match. And making sure clients are receiving the message and we are talking to them about it, and letting them process their sadness, frustration, worry, whatever their genuine response is, can be helpful.”
A communicable diseases plan
A Peak Resilience, their informed consent document has a recent addition: a communicable diseases plan.
“As a result of COVID-19, we created our no-symptom policy, which is basically that we wanted to recognize that we’re moving back to in-person appointments,” she says. “Some people have a real preference for in-person appointments, but we still are not going to allow for in-person appointments if they have any communicable disease symptoms or if their mental health counsellor is symptomatic.”
But if someone has symptoms, that doesn’t mean the session is cancelled or that the client doesn’t have to pay — the session simply moves online. And in a world that may never be officially “post-pandemic,” it is a way of moving forward in a more intentional way.
Vacation time
Taking time off can be hard for counsellors and their clients.
“I work primarily with people experiencing PTSD and trauma, and it is incredibly hard for them when I take time off,” says Turner. “But if I do my own therapeutic work — I know in order to stay safe for them, I have to take my time off, and I’m allowed to take time off — and if I engage with myself from a place of abundance — that I can be enough, even when I take time off, and I don’t have to sacrifice myself — then I can communicate it with more ease and grace.”
She generally waits until after the full 50-minute session to let clients know about the time off and to make space for them to process it at a time they are not covering the cost.
“I can help the client process how scared they’re going be when I take the time off and help them set alternative resources and safety plans from a place that feels lighter and safer for the client,” says Turner.
Hollinshead describes vacation planning as “two people working out our schedules with one another.” The plans may even be tentative but they are always discussed.
For counsellors who have a hard time talking to clients about vacation time or giving themselves permission to take time off, Hollinshead says it’s a good plug for supervision and consultation.
“I call supervision clinical self-care because it’s like you’re being witnessed in the work, you’re being supported, you’re being challenged and held accountable, but then you’re also being supported in your humanity,” she says.
In the end, these are your decisions
How each counsellor feels about these policies can affect their relationships with their clients.
“If we engage from bitterness and resentment, we undermine the very purpose of what we’re doing here,” says Turner.
Every counsellor has to do what is best for them.
“I think what’s most damaging is when we forego the right to turn inward, and we do things because other people in the industry do them or because we feel like we have to, then we’re not doing it in a way we feel proud of and then we are not modelling for our clients and the whole relationship can become compromised or sacrificed and our behaviour doesn’t give the client the impression you want to give them,” she says. “And we can easily turn to blame when we’re feeling stuck.”
Turners says counsellors may want to consult their supervisors or their own counsellors if they are feeling resentful or bitter, so they can explore where the anger is coming from, and they can get clarity on their wants and needs.
“And that’s probably why BCACC doesn’t dictate it,” she says. “Because if it was dictated and I was doing something that didn’t feel aligned for me, I couldn’t do it in a way that’s most helpful for clients and it could undermine my relationship with my clients and, ultimately, their therapy.”
“If we can’t claim it for ourselves, how can we authentically ask clients to claim it for themselves?”
Resources:
Book with Lavender Counselling’s Supervisors: https://www.lavendercounselling.com/%20post-graduate-consultation-info/
Lavender Counselling’s 8-month Supervision Group: https://app.acuityscheduling.com/ schedule.php?owner=11474685&appointmentType=44657976
Jennifer Hollinshead runs a monthly supervision/consultation group: https://peakresilience.janeapp.com/#/staff_member/1/treatment/156
