Have you ever wondered how to manage an employee or an independent contractor whom you felt suffered from a personality disorder? It is an incredibly challenging task. Let us begin our discussion by assuming that this is an employee that you would prefer to keep. Obviously, if it were not so, you could arrange to dismiss them. But when they have some merit, offer some value or contribute some skill that you prefer to be able to access, you may want to keep them for a time. The necessary managerial calculus is a constant and ongoing reassessment of the worth of the employee/independent contractor versus the cost of the damage they do to your organization. Perhaps nothing is more clearly at issue than the cost- benefit ratio that a manager/owner has to calculate with regard to these individuals. You often make an investment in the contractor or employee, such as equipment, marketing, training, etc., before you realize that they have issues that make them difficult to manage.
In today’s world, many therapists’ practices are structured by an owner who undertakes to provide the basic necessities of business operation. These owners sign contracts to be responsible for the rent, hire secretarial help, manage the storage of files, track accounts receivable, pay the bills, market the practice and provide the clinical supervision required by the state. In return for taking these risks and maintaining these responsibilities, they make a deal with the independent contractor, who is a licensed individual. The licensed individual will provide the direct client services in an ethical and appropriate manner. This is a win/win for both the practice and the therapist who is an IC (independent contractor.) In the field of psychotherapy, the client “belongs” to the therapist not to the practice. If the therapist leaves the practice for any reason, the client always has the option to go with them. The practice must retain records and the therapist who leaves must retain records of the work that was done. They must both follow the rules of HIPPA and the ethical codes regarding custody and availability of records. Generally these practices are created around the idea of a fee split. The provider of the services, in this case the therapist, receives some agreed percentage and the owner of the practice receives the rest. This is true even when the practice accepts third part reimbursement. Usually the fee split breaks in favor of the owner of the practice and often has several break points for performance where the split changes. Usually these contracts can be cancelled with thirty days written notice by either party.
In my experience, the owner of this type of practice is also a licensed provider who has clinical skills and is comfortable with undertaking the financial and ethical risks in return for the payoff of the percentage of earnings of the various independent contractors whom they “hire.” They actually don’t hire them, of course, because then the practitioners would be employees and the rules and issues would change. However, the challenge I originally posed may arise in either setting: What do you do with a practitioner whom you feel has an Axis II personality disorder? Are they worth keeping? If so, how do you manage them to minimize the distress they inherently cause in the work place and restrict any damage to the client from the operation of their particular disorder? And, yes clinicians often have diagnosable conditions. Some even have Axis II disorders. They still practice and often do a great job when their skills are applied to clients who suffer from disorders different from their own. It might be interesting to ask those clinicians with whom I have worked through the years as a co-worker, supervisor or teacher what they think my diagnostic labels would be….., but I really don’t want to go there. Some of them read this blog and may feel compelled to respond.
Generally, when one presumes that a therapist has an Axis II disorder, one works to “lean” them in the direction of a client population who is not suffering from the same disorder. Often these clinicians have already done that for themselves, they may suffer from a passive aggressive disorder (Axis II) in their personal and professional lives, but they may specialize in working with children who are ADD, working with families that have co-dependency issues or depressive issues. This should pose no ethical problem for the therapist or for the practice at large. But it will pose a problem for the manager who is trying to manage the practice because the therapist will act out their personal issues within the office and they will bring some of their challenges into the relationships they develop within the office that have nothing to do with their client base. The other employees of the office will be angry and frustrated with them and with the manager for not dealing with them more efficiently. A lot of tension builds within the practice because no clear challenge is made. For example, passive aggressive behaviors cause others to get very angry and frustrated, but the individual that engages in them will claim innocence and be very hard to pin down and confront. As the manager of the practice, you need to know that this will happen and have a plan for regulating the relationships so that your office does not explode from frustration. In order to do this, you have to follow the general rules for dealing with individuals that have passive aggressive behaviors. You must have firm boundaries and rules, and you must enforce them neutrally and consistently. This is difficult to do because the individual involved will deny the accuracy of any challenge and will work hard to deflect any responsibility for their actions, or lack of actions. As the manager, you will be frustrated and your other staff will feel angry! Also as the manager, the goal is for you to manage the practice so that the clients are well served and that the staff does not explode. You need to make sure that you are not paying a greater cost in investment of energy than it is worth to keep this individual working for you.
Success in this domain is based on a constant and on-going reassessment of the value of the contractor whom is Axis II disordered. Are they worth the trouble? Can you maintain a consistent set of behavioral expectations with consequences for a contractor that is not an employee? Can you keep the other staff from playing the game of “I got you now, you S.O.B.” (See Eric Berne, Games People Play.) You must remain professional and must not get emotionally involved. Enforce the rules and require the appropriate behavior from your independent contractors, even when they claim innocence and ignorance. Some common statements you will hear are: I did not know. I did not do that. You misunderstood. The rest of the staff does not like me.
It is a challenge to work with independent contractors in the first place. It is a particular challenge working with one who is Axis II disordered. When you begin a relationship with a new contractor, it is usually not obvious that these issues exist. But once you are aware of the problem, you must deal with it on several levels. At best, your efforts are a holding action against disaster. You can contain the problem for a while, but eventually you will need to replace the contractor and work constantly to protect the client base that you serve. You have an ethical and legal obligation to the clients when you bring these clinicians into your practice, even though you are not the provider with direct contact. You also have an obligation to the clinician. If you undertake to “hire” them and work with them as professional providers, you must supervise, manage and consult with them to keep them coloring within the lines at all times. This is more difficult than you may imagine and it is seldom worth the cost in the long term. In summary, these clinicians are challenging and may contribute to the bottom line of the practice, but they will cost more in energy, frustration and exposure to risk than they are worth. You cannot technically “diagnose” them and you cannot force them to get counseling for their disorder (you can encourage, but not require.) However, you can manage them efficiently, consistently and hold them accountable to a standard of behavior. In fact, you must do this to be ethical and to protect the client base that you both serve. You must also know that your office will be in a constant state of uproar and the other staff will be angry and upset continually (and perhaps, the clients will also.)
Keep in mind the fable of the scorpion and the frog. For those who are not familiar with it: A scorpion and a frog arrive at a river bank in flood. The scorpion talks the frog into giving him a ride across the river by promising not to sting the frog, paralyzing him while they were in the middle of the river. Of course the scorpion violates his promise and as they are both sinking into the river to drown the frog asked, “Why?” The scorpion responded, “It is what we do!” The scorpion could no more go against his nature than he could fly. When you know that you are working with a scorpion and you get stung, it is your responsibility to deal with it, because the scorpion is made to sting. Protect yourself, your practice and your clients by having good boundaries and clear expectations.