The overscheduled practitioner

By Ellen Anderson, Ph.D
January 5th, 2024

“People don’t change.” This was relayed to me within my first week on the job by a psychologist, 30 years older than myself. As a researcher, he had some basis for this statement and was referring to enduring behavior patterns, such as my tendency to take on too much and predictably, feel overwhelmed.

Over the course of our 30-year friendship, this has remained a fundamental disagreement between us. Psychotherapy is based on the premise that people are capable of change! At the same time, he was correct, core personality traits, such as flexibility, tolerance and empathy are important in a therapist, but in excess, can contribute to the tendency to sacrifice the needs of the self for the needs of others.

I have pursued the quest for an optimal work schedule for decades with near messianic zeal. It is only in the setting of private practice that I can identify the factors within my control that contribute to chronic overscheduling.

Does any psychologist in private practice achieve the goal of an optimal schedule? The number of available hours in which to see patients in any given week is limited. Therapists have the autonomy to determine when they see patients. Why then do so many of my colleagues feel as though there are never enough hours in the day?

Many self-employed psychologists err on the side of overscheduling, as a hedge against the inevitable cancellations and reschedules that occur. Yet while we expect cancellations as part of routine practice, often we leave little margin for ourselves in terms of unplanned time off to be sick or care for others. The pattern of overscheduling and under-estimating our own needs leads to frustration and burnout.

It is tempting to think that with the right tools, I could create the schedule of my dreams. In a previous life, working in healthcare, I underwent 40 hours of training in managerial processes designed to improve performance and efficiency.

The model promised increased productivity and decreased waste. I can’t speak for the organization but in my case, it simply didn’t take. Working collaboratively to define strategic priorities was initially invigorating. But it created a “begats problem.”

Strategic priorities begat value stream mapping, which in turn begat the Kaizen (don’t ask), which begat a monthly dashboard, whereupon all efforts toward achieving strategic priorities were quantified and progress (or lack thereof) were denoted with green and red symbols, projected via PowerPoint and reviewed over meetings lasting multiple hours.

This, in turn, begat more meetings. You get the picture. It seemed to be the opposite of efficient.

Despite my disillusionment with the organizational model, I remember the concept of “load leveling” with great fondness. An emergency room provides a good example. With proper load leveling, an emergency room would have little wait time, patients would be triaged effectively, and sufficient resources would be available to treat patients based on typical peak hours achieving a more optimal throughput.

In theory, we can implement this strategy by prescreening new clients to determine whether their scheduling needs align with our availability. However, patient needs are dynamic. Most people must be sufficiently distressed such that they are willing to seek out therapy. In that context, a client may be initially willing to take time off work for daytime appointments but find it unsustainable over a longer period.

Some personality traits to curb, in service of combating chronic overscheduling include the following:

Impulsivity: Avoid the tendency, especially at the end of a session to impulsively schedule an appointment into a time that you did not intend to work. If the desired available slot is not available, book the patient further out and set up a cancellation waitlist.

Self-sacrifice: Private practice requires large chunks of time devoted to charting, billing, scheduling, and other forms of practice administration as well as the basic human needs to take breaks, eat meals, and exercise! To my great detriment, I have been prone to prioritizing the scheduling desires of my clients over my own need for a balanced schedule. Unfortunately, this maladaptive behavior is reinforced with increased revenue, making it a tough pattern to recognize and break.

Flexibility. Stay firm in sticking to the schedule you have set up, but build flexibility into your calendar by leaving time slots unscheduled. There is nothing quite so appealing as seeing open space on your schedule! And conversely, there is nothing quite so daunting as facing an overscheduled day, week, or month. Despite best efforts, therapist schedules will always have some degree of unpredictability. While we can’t prepare for the unpredictable, leaving ourselves a cushion of unscheduled hours provides room to adapt and accommodate ever-changing needs.

Narcissism: It is easy to imagine that our clients need us more than they do. But patients have many strengths, and no therapist is truly indispensable. It is good for clients to know that their therapist has full faith in their ability to cope with scheduling delays. More importantly, if you consistently don’t have the room in your schedule to meet patients’ needs without sacrificing your own, helping them to connect to a new therapist is the ethically correct choice.

In the novel “The Measure,” author Nikki Erlick writes, “I arise in the morning torn between a desire to save the world and a desire to savor the world. That makes it hard to plan the day.” We all grapple with time or the lack thereof, but as therapists, we should model for clients the behaviors that are most aligned with the values we wish to impart.

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