Managing Your Waitlist: How to Tackle the Ethical Dilemmas

By Lynn Grodzki

Published in the Psychotherapy Networker Magazine, July/August 2022

Q: Since my caseload is full, I’ve started a waitlist. What’s the best way to manage this list? And is it even ethical to ask potential clients in need of care to wait until I have an opening?

A: As we all know, people seeking psychotherapy are often at a low point in their lives. Anxious, depressed, and vulnerable, many may have taken a deep breath and finally made a call, only to find that you have no current openings. If they opt to be on your waitlist, their experience of being put on a list and then waiting to hear from you will be a reflection for them of how they’ll fare in your actual office, once they become clients. Your waitlist expresses a lot about you as a clinician, as well the principles and purpose of your work.

Here are some considerations for having a list or not, as well as approaches that constitute best practices for establishing and maintaining one.

Why Have a List?

Having a list isn’t mandatory, but it’s becoming more common for therapists in private practice. Why? Even if you simply close your doors when your caseload is full and recommend callers look elsewhere for help, they’re likely to counter that they’re coming to you by referral, or have found you based on your unique specialty, your office location, or the insurance you accept. They’ll tell you that they’re sure you’ll be the right therapist for them and are willing to wait. We therapists are built to help people in need, so it’s hard to say no when they make a plea.

The scarcity of therapy providers in the market is another incentive for considering a waitlist. Over much of the past 30-plus years that I’ve been writing and consulting about private practice, more than enough therapists to handle the flow of clients seeking services seemed to have been available. But since COVID, the landscape has changed: we now face the nationwide crisis of increased demand for mental health services and a shortage of therapists available for treatment. Some therapists have retired or left the profession due to normal attrition, but others have left because they felt burnt out or were generally frustrated by insurance demands. As a result, finding an available therapist has become its own trial and burden.

A recent article in The Washington Post underlined this reality, giving the example of a woman who needed grief counseling and tried 25 therapists in the Los Angeles area, only to be told each was full and not accepting new clients; she kept a spreadsheet to track her frustration and despair in finding help. The experience of searching for counseling is only increasing across the country. People seeking help are confronting a mental healthcare system at or beyond capacity, its inadequacy for this moment plainly exposed.

Offering to put people on your waitlist can be an accommodation that addresses the issue of therapist shortage. Knowing that treatment will be available soon can offer hope to an anxious caller. It can bring solace to those who, like the woman in Los Angeles, are being traumatized by a fruitless search. But if waitlists are to be a new norm, it’s important to plan to set up yours in the best, most ethical way possible. To do this, start with defining its parameters.

A Boundary, Not a Border Wall

A waitlist is a tool used for setting good boundaries around your practice, protecting the limits of your healthy caseload, and securing the work–life balance you want. It’s not designed to put you in the role of having to guard a wall between those on the inside and those amassing on the outside. Optimally, it allows you to offer your skills and services in the best way.

Even with acknowledging the limits of your time, energy, and capacity, having a waitlist can evoke therapist guilt: I should do more. Maybe I can just add another block of time each week. Maybe I just need to work faster or harder. I remind therapists who struggle with this dilemma that most of us work consistently and diligently with few breaks in our schedules. Deciding on the optimal number of client hours each week and then staying within those limits is a way to take care of the primary asset in your practice—you.

That said, thinking through the following questions can help you define your boundary:

• Who belongs on the waitlist, and who doesn’t? (What’s your definition of urgent versus nonurgent symptoms, and how will you screen potential clients?)

• Is the list just for new clients, or do returning clients belong there too?

• Is the list first-come, first-served, or are people ranked by other factors, such as the specialty you offer, or the level of their treatment needs? (Perhaps you give preference to those who’ve been in therapy before, or to those who’ve completed a treatment program for addiction?)

• If you’ll be regularly monitoring the list and finding room for new clients or knowing that you won’t have openings for some time, when will people hear from you next, and how?

• If you don’t monitor the list, how will you make contact if a space opens up? Do you want the callers to take responsibility for checking back with you? If so, how often and what’s the preferred way—phone call, email, text?

• Do those on your list require special care and more frequent contact, based on physical vulnerability, psychological diagnosis, or other issues that suggest you offer additional accommodations as they wait?

Once you have a better understanding of your waitlist logistics, the next step is reviewing your process of screening calls.

Screening and Monitoring

Careful screening is the best way for you to decide which callers have issues that need immediate care and prompt referrals out to a hospital, clinic, hotline, or other available provider—versus who is appropriate to wait for treatment. Most therapists do a brief screening by setting aside time for an introductory phone call, or by using an email survey or online poll for this purpose. After screening, make sure to keep notes of the interaction, such as a log of who called, as well as when and what you recommended.

Communicate the parameters of the waitlist clearly to those who call. Include specifics to alert potential clients to how long to expect the average wait for an opening. The best way to estimate your wait times is to review your caseload. How long does the average client stay with you? Do you usually work short-term or long-term? What level of intensity do your clients require? Do you see them weekly or every other week?

Post this estimate on your website, send an email to those who’ve requested to be on the list, or pin it to your social media page, so that those wanting to work with you can easily find and understand the policy and purpose of your waitlist.

Once you determine that a caller is not in crisis and is appropriate to be placed on your list, you need to keep a different log for them. A spreadsheet works well, to allow you to track whom you’ve placed on this log, what symptoms they’re presenting with, the level of urgency based on your brief conversation, and the best contact information to reach them. I recommend that you monitor the log monthly, to update those on it with a brief phone call, text, or email to ensure that what seemed to be a minor diagnosis hasn’t become acute. Remind people of the status of your openings, ask to be alerted if their situation or symptoms have become more acute in the past month, and if they have gone elsewhere for therapy.

Referrals and Other Resources

Years ago, if I couldn’t find space in my practice for a new client, I’d try to find a good referral. Currently, I can’t justify the time to do this kind of search. A therapist who sees Medicare patients told me she can spend days looking for another Medicare practitioner with scant success, given that they rarely have openings in her locale.

To save time, you can offer a prewritten list of practitioners that people can contact themselves, with the caveat that these referrals you offer may be full. Include any larger group practices that might have a more rapid turnover, or at least online directories that offer detailed provider descriptions.

Consider offering free resources for those on your waitlist. For instance, a couples therapist could alert those on her waitlist to free videos available on her website, with tips for couples in the midst of conflict. Another therapist might share helpful resources for managing depression and anxiety to her social media feeds, which people on her waitlist can follow. Your resources might include treatment centers for acute care, podcasts that are self-help in nature, books that you often recommend to clients, and articles or information that might be helpful for those who are waiting.

Ethical and Liability Concerns

Last month, I got a call from a therapist who was just getting started in private practice and waiting for the results of her licensure exam. She said, “I know lots of people are seeking therapy, and I thought it might be a good idea to build a waitlist of potential clients, even before I’m set up in practice, so that I can hit the ground running. I saw this idea on YouTube. What do you think?”

As I told her, I believe that intentionally building a waitlist as a marketing strategy for starting a practice comes close to crossing an ethical line. But the ethics for practicing clinicians around keeping waitlists are harder to identify. I’ve perused the current NASW and APA codes of ethics and see nothing specific to waitlists.

In terms of professional liability, one unanswered question floats to the top: is a person on your waitlist considered to be your client? For example, if someone agrees to wait to see you, at first reporting a nonurgent level of depression that then advances to a suicidal level, could you be sued for malpractice or dereliction of duty should that person self-harm?

Frederic Reamer, professor at the School of Social Work of Rhode Island College, suggests that a clear explanation of the limits of your responsibilities, as you understand them, might be expressed in a statement like the following, sent after someone is placed on the list:

Thank you for inquiring about my counseling services. As I explained, at the moment I do not have room in my schedule to offer you an appointment. We have agreed that I will place you on my waitlist and notify you when I have an opening. In the meantime, please understand that I am not able to provide you with emergency or other counseling services. If you feel the need for counseling services before I have an opening, I encourage you to seek another provider. In the event of an emergency, please call 911 or visit the nearest emergency department.

Reamer also cautions that in the process of drafting a statement such as this, therapists may want to consult with a local attorney who specializes in healthcare law in the state in which they practice and can advise on risk-management protocols.

These questions and concerns reflect the changing nature of our times, where waitlists are becoming more common. Our ethical codes and educational policies must keep up with shifts in the profession, and this topic will need to be reexamined again and again. Waitlists that have been set up with good structure and clear intentions can help us balance the demands of a growing interest in our services, protect the natural limits of our practices, and reflect the goodwill inherent in our chosen profession.

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