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Podcast Episode 25: How to Handle Payment for College Students When their Parents are Paying

Enlightened Practice Podcast

Dr. Ken Braslow and Dr. Kari Kagan answer a listener’s question about the business side of practice when handling college students and their parents want to talk about their care. Things like knowing who made the decision to see the therapist, setting up the initial interview, scheduling, payment, and other great details are discussed by our hosts in this interesting episode of the Enlightened Practice Podcast.

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Transcript of the podcast

Ken: Hi, Kari. Welcome back to the podcast.

Kari: Hi, Ken. Great to see you!

Ken: Likewise. Today, we have a question from a listener about handling college students and the joys of working with them. I actually really enjoy working with college students. They often have good energy, or at least they feel liberated from having spent the previous 18 years with their parents. And so I like their spirit. I like the freedom that they feel in college. However, they can be challenging to work with, to put it lightly, when it comes to the business side of practice, and I’m thinking specifically of handling when their parents want to talk about their care, setting up the initial interview, payment, scheduling, that sort of thing. So, I think that’s a great topic for us to be chatting about. I’m curious what’s your take on working with college kids? And before we get into the particulars, anything that you love or don’t love about working with them?

Kari: Yeah. I do enjoy working with college students. However, I will say that one of the parts of it that I find trickiest is dealing with the parents, and that part of it’s because it can be difficult to navigate because a lot of times they are the ones paying for the session or still even in college. A lot of parents are still heavily involved in their kids’ lives. And so I’ve always tended to focus on adults for that reason actually, to try to avoid dealing with the parents. But I think it’s helpful to know how because even with that intention, I still have ended up working with a lot of people who were supported by their parents in some way or another. So it’s a really important thing to figure out.

Ken: That’s true. It’s not just college students. It could be any dependent relationship where the patient is an adult.

Kari: Yeah. So, I’m curious because I know that you do work a lot with a younger population. So, I was curious to hear how you have navigated some of the issues that can arise there.

Ken: Yeah. So, I’m thinking about different scenarios. One is when the parent calls and says, I’d like you to see my adult child, and right away that makes me pause and think about why isn’t the adult child calling me and why are the parents calling me? And sometimes it could be clinically well-founded that the college student, let’s say, is too depressed, too anxious to make the call, or two disorganized and very caring parents think, well, I’ll try and make this process go easier for you, especially if the parents are thousands of miles away and they want to do whatever they can to help. 

And so in that case, I will talk to the parents, but I do require a conversation with their child before I agree to move forward because, one, I just don’t even know how it would work physically. How would the child show up in my office if they have no idea who I am? And the parents just kind of booked a time for them and it just seems odd. But more importantly, I really want to assess, similar to working with teenagers in general. Do you even want to see me? Are your parents making you see me? Where is this coming from? 

And I think that’s important when you think about psychologically or psychodynamic, what this treatment is going to look like. And even if you’re doing CBT, are they going to be invested in doing the homework if their parents made them come to see me? You know, probably not as much. So, I have some colleagues who won’t talk to the parents at all, other than to get the child/college student’s contact info. But I do find it useful to talk to the parents to get a little bit of background. Similar to when I’m working with kids and teenagers. Parents always provide a layer of background that the kid never seems able to provide. So, I’m curious if you got a call from a parent of a college student. How would you approach that?

Kari: I have gotten many calls from parents of all ages, for sure. And yeah, similar to you, it always kind of raises not necessarily flags, but I start to really wonder why the parent is reaching out and not the kid? And there really could be so many reasons. It’s not always like the parent is forcing the kid to go to therapy. Sometimes the kid is really busy and they have asked their parents to help them because it can be time-consuming and hard to find a therapist, and sometimes it is more of the parent feeling pretty concerned and desperate, and it’s more of them doing the work for the kid. And that’s a different story. 

But usually I don’t actually have any long conversations with the parent. The ideal situation for me is to have the client reach out to me because for me it is. I do like to see that step taken that there’s the motivation enough to reach out to the therapist just to get started. Sometimes I’ll say like, or you can give me their number, but that’s not my preference, because if someone really wants to come to therapy, I do think that taking the first step is important for them to be the ones to reach out. 

So, I often will just say to a parent, thank you so much for calling. The way this works for me is I would start with talking to their child and I would of course validate their concerns or say, it’s so great that you’re reaching out for them or whatever it might be, and just say like, I’ll start with them and we’ll let you know. We’ll come back to discussing their involvement and role once I get a sense of what the client would want their involvement and role to be.

Ken: I think that sounds reasonable. One thing that I have yet to encounter with a college student is them saying I’d rather pay than my parent’s pay. So, sometimes they want their parents involved. From a clinical point of view, sometimes they only want them involved to pay for treatment. And I’m curious if you do anything different based on either of those scenarios?

Kari: If it’s just the client wants the parent to be involved financially or clinically?

Ken: Yeah. Do you screen out if they say, no, I don’t want you talking to my parents?

Kari: No, not necessarily, but I just would do a lot more information gathering, because it can be helpful to have collaboration to get different perspectives on a situation. But I wouldn’t make it a condition that the only way I would see a person is if they let me talk to a parent, for example. Unless there was some really interesting circumstance that it felt imperative that I talked to a parent, like maybe if there was a risk thing going on.

Ken: That’s what I’m talking about.

Kari: Yeah.

Ken: Yeah. If the parent is saying to me that they’re really worried about their child in terms of depression, safety, that’s when personally I say I need to have that parent involved. But if it’s just run-of-the-mill anxiety, or depression, or ADHD, yeah, then I agree with you. I don’t require it.

Kari: Yeah.

Ken: So, in terms of your logistical side, setting up the policies or practice policies with the college student, how do you handle that with them?

Kari: Well, I’m going to be curious to hear how you do it because it’s been something that I’ve experimented with over the years. But usually, the policy is that if a kid is over 18, then everything we talk about is confidential. And if they wanted me to be able to talk to a parent, then I would have them sign a form that gives me permission to do that. And we would get really specific about what they feel comfortable with me sharing or not sharing. 

I believe as would be the case with anyone, that if risk was involved, then that would be a reason to break confidentiality. So, I would really want to be clear about that with the client upfront. But it’s gotten tricky when the parent reaches out and they want to know about how it’s going or maybe sometimes even threatening to stop paying or something like that. And so it can get kind of tricky. So I’m curious to hear how you if you have some strategies for setting up for those possibilities.

Ken: Sure. Well, if the parent is calling me saying, how’s my child doing? I will invite them to talk with their child and ask the child how the child is doing. But that might be part of the problem. And for whatever reason, it can’t or won’t be done. And so then I will encourage them to come join a session. And before I do that, I talk with the college student about what would it be like to have your parent in session? What would you want to get out of it? What should we not cover with them? How can we get something out of this? And how can we use this for the good of our work together? 

If the child, the college student really doesn’t want to talk to the parents and the parents really don’t want to talk to the college student directly, then I will present to both of them this conundrum. And I don’t feel like I need to be the one to solve that for them. I put it out there to them and say, you know, this is really for you guys to think through. And if it means that treatment stops then I would rather protect the confidentiality and have treatment stop than violate confidentiality and then in the hopes that treatment continues. That doesn’t feel tenable to me. And I think the therapy would be tainted.

And even if I’m just seeing somebody for meds, it doesn’t matter whether it’s therapy or meds. The college student needs to call the shots and at that age the development of autonomy is really solidifying. And even if college students are going to make a decision that I wouldn’t make about their own treatment and I will defer to them usually as long as I feel like it’s safe and not contraindicated, because it’s so meaningful for them to develop that sense of autonomy. And that’s a big part of the work we’re doing. So to then say, well, I have to tell your parents because they are asking, totally defeats the therapeutic message behind that. 

So, fortunately, I haven’t been in too many scenarios where a parent has held the work hostage, kind of. But that’s also why at the beginning, in the policies, I make it real clear that the parent may be paying for it, but it doesn’t buy you anything. It doesn’t buy you access. It doesn’t buy you anything other than my time with your child. And will that work for you? And we have that conversation upfront. So that way it’s really clear what the boundaries are. And if it’s not okay with them, I’d much rather know that upfront. And we can all move on.

Kari: Right. Yeah. Have you ever found yourself in a situation where like one or the other, either the parent or the child wants to terminate, but one or the other wants them to stay? And I’m just curious, how do you navigate that?

Ken: Yeah. So that’s interesting. I’ve had college students who wanted to terminate, and I guess, I’m less concerned with what the parents think at that point. I try and help them think it through, just like I would any other adult patient or client about what are the pros and cons and what are their goals, and do they meet their goals? And if they didn’t, what is their plan? What were the obstacles? What are the alternatives? Just like any other intervention or alternative treatment, just try and help them think it through so they can make a really good decision. 

And I think that goes back to if the parent pays, that doesn’t buy anything else in terms of a guarantee of a particular kind of treatment or longevity of the treatment. And similarly, at the beginning, I tell the parents, just like I tell my adult patients, we’re just going to meet for a consultation and let’s see if it’s a good fit, a mutually good fit and if it is okay. But if it’s not, this isn’t a guarantee that I’m going to be working with your child for the rest of your life or the child’s life. We just need to start and let’s see how things go.

Kari: Yeah, that makes sense. 

Ken: So, then the challenge that I have run into in my practice is no shows. And what happens when the college student no-shows and the parents get the bill. And I’m curious what your take is on that, what your experience has been with that?

Kari: Yeah. Well, first of all, I would definitely do my best to make that clear in the informed consent that that is the policy. And so when it does happen, it wouldn’t be hopefully a surprise to the parent or to the child. I haven’t done this before, but I can see that if that becomes an issue right where maybe it’s recreating some kind of dynamic between the parent and the child.

For example, the child is irresponsible or something with the parent, and inconsiderate and all that kind of stuff. That’s just a lot of good clinical work. And that could be a potential reason to bring the parent into work through that. It could be a good thing to process with the child to understand like what are some of the consequences of their actions. But I would still hold firm on the policy if it’s just like a no-show and not with any emergency behind it. And hopefully having covered that in the policies, you know, everyone is prepared, but a lot of stuff to talk about in session with both client and potentially parent.

Ken: Yeah.

Kari: What about you?

Ken: Yeah. I feel like there’s so much useful data that comes out of it. If a kid has ADHD, we use that to talk about project management and time management and how many other things are they no-showing for outside of just our work together. If it’s a reflection of anxiety or depression, we use that to talk about our work together. How meaningful do they find it? Are they? 

If it’s more psychodynamic work, we’ll talk about is there something about our work that is recreating something outside of our work that they are feeling vulnerable about or getting triggered by, and how invested are they in the work? It’s also true that college students’ schedules change all the time, seemingly, or at least on a quarterly, or trimester, or semester basis. And so that can be challenging if they don’t have just basic time-keeping calendar skills. I see this in college freshmen a lot. They just space out. They don’t even have to have ADHD, their friends wanted to go to lunch with them and they go to lunch and they like totally spaced out on our session. 

So, it doesn’t always reflect something really deep and meaningful clinically. Sometimes it just reflects that they’re a freshman in college, I just try and meet them where they’re at and see what’s up with that. What I’ve done with policies in the past is, of course, I have the college student sign off on my policy since they are the patient, but I also have the parents sign off and I had a special version of policies just for parents outlining what we’re talking about here. But what I didn’t do early on, which I only started to do later after it bit me was to really cover the concept of the no-show with the college student because they don’t get it. They really don’t get it, or at least the ones I work with most of the time they think, but I didn’t go to session. So why are you charging for it? They just don’t make that connection that they’re paying for the time.

Kari: Right.

Ken: So, we talk about, if you no-show for your airline flight, they keep the money. It doesn’t matter. You didn’t buy the flight. You bought the right to sit on the airplane. And whether you do or not is irrelevant to the airline.

Kari: Exactly.

Ken: I talk about that beforehand and I also tell them, you better not no-show, your parents are going to be furious. I just put that out there because I realized that if I was too nonchalant about it or just glossed over it, they really don’t get it and they need to hear that. For some families, I set up the portal so that the parents can enter their credit card info, but the parents do have their pain. So, of course, they want the superbill to submit for reimbursement. And so they can see that the kid no-showed and then they’re not going to get any reimbursement for it. So, I tell the kids this upfront, this is you’re not going to be able to like pull the wool over your parents here. 

And if you really want to keep your parents out of our work, no better way to screw that up than to no-show because most parents are none too thrilled about it, and that will pull them in closer to our work. And to even talk about when I say you need to give me two days’ notice, that doesn’t mean text me on Saturday for a Monday appointment and say you’re canceling. That doesn’t work. It’s business days. So, I really try and spell out for them and I think a lot of it is just they’re just new to the real world.

Kari: Absolutely.

Ken: But, I did have a scenario years ago where an established patient who I had seen for a couple of years that no-showed like once or twice within a month, and the parents said they wanted to pull the plug. And that was really, really painful because the college student was nowhere near ready to be done with the work. And it was a reflection of long-standing issues they had with the parents. And I’m sure the college student felt their own level of guilt about no-showing. And it was a real pickle.

Kari: Yeah. I think it’s so great that you’re just very straightforward because it does seem like at that age they might really be needing that kind of transparency, and direction, and understanding from the get-go to set them up for success as opposed to assuming that they already get it and all that kind of stuff because that might be one of their first real experiences where there’s a major financial consequence if they miss a session. So it’s great. I think that really does them a big favor to help set them up for success as opposed to failure eventually.

Ken: I think they don’t also have any clue how expensive treatment is.

Kari: Right.

Ken: I try and just be real with them, better that they know beforehand and they have a little bit of fear of God in them or at least the fear of their parents than that they are blindsided or just really upset. Not like they feel like they didn’t get full disclosure even though they signed the policies, which spells all of this out anyway. And I just realized how many college students sign it, but they never actually read the policies.

Kari: Right.

Ken: And it was just a checkbox to make it go away.

Kari: Yeah.

Ken: So, I’ve learned the hard way in some of those cases. Well, any other thoughts you have about working with college students, scheduling, billing? 

Kari: No. I mean, I understand now why a long time ago I started to veer away from working with because I saw a few more earlier on and now I’m remembering all those experiences of having to deal with the parents. And that’s just not for everyone, and me, included because it does add a layer of work for the therapist. I mean, these problems still exist with all people, but I’m just remembering, oh yeah, this is tough. 

Ken: I think when there are a lot of family dynamics issues, it gets played out in the treatment. If it’s the parents were just being project managers for the kids and it’s not really about family dynamics, then I find in those cases things roll very smoothly and it’s typically not a problem.

Kari: Yeah.

Ken: Okay, well, good. I’m glad we could cover this. We were intending just to spend five minutes on this as a quick question, but there’s just so much to say.

Kari: Yeah.

Ken: So, I think we’ll stop here for today and we look forward to covering more questions with you soon. Thanks so much for coming on. 

Kari: Yeah. See you soon.

Ken: Okay. Talk to you later. Bye.

Kari: Thanks. Bye.


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