The Private Practice Success Podcast

23. Over-Servicing in Private Practice

• Gerda Muller • Episode 23

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In Episode 23 of the Private Practice Success Podcast, Gerda tackles the sensitive and often misunderstood topic of over-servicing and under-servicing in private practice. 

With her signature clarity and insight, Gerda defines these concepts, explores their causes, and highlights their ethical and practical implications for clinicians, clients, and businesses.

In this Episode, you will learn (among others):

  • The definitions of over-servicing and under-servicing in allied health.
  • Key factors contributing to both over-servicing and under-servicing.
  • The risks these practices pose to client outcomes, clinician integrity, and industry trust.
  • How to achieve the right balance of care using evidence-based practices and client-centered approaches.
  • The importance of understanding Antonovsky’s Salutogenesis Model and its application in private practice.

Who This Episode Is For:

  • Clinicians aiming to deliver ethical, high-quality care.
  • Allied health professionals wanting to understand the balance between meeting client needs and maintaining business viability.
  • Practice owners ready to embed data-driven, client-centered care into their service delivery.

Gerda also shares her philosophy of empowering clients to move beyond the absence of symptoms towards a life of health-ease, purpose, and meaning. Tune in for practical advice and actionable insights that will help you build a practice you can’t stop smiling about!

Connect with Private Practice Success & Gerda here:

 Well, hello there amazing private practice owner. My name is Gerda Muller and you are listening to the Private Practice Success podcast, and this is episode number 23. Today I'm going to talk to you about a really interesting topic, and the topic is - Over-Servicing in Private Practice.

Now, I want to encourage you to quickly reflect on when I said the word - ‘over-servicing.’ What were the thoughts that hopped into your head? And what did you feel? I think it's really important to check in, because over-servicing is potentially a highly contentious issue.  I have found that people have got really strong and very valid feelings, thoughts and opinions about over-servicing and how that could potentially manifest within private practice, as well as in the broader allied health industry. 

So we are going to delve into this today, and I'm going to jump straight in and I'm going to put it out there very clearly:  I am 100% against over-servicing, not only in private practice, not only in allied health, but anywhere for that matter.

Now that being said, I am also 100% against under-servicing. Because you know what? Under-servicing in my mind equals negligence, and I'm also not in the business of being negligent when it comes to looking after my clinical clients.

So let's start by looking at a bit of a definition of what is over-servicing, and what is under-servicing - just so that we are on the exact same page when it comes to discussing these concepts. 

Defining Over-Servicing & Under-Servicing in Allied Health

Over-servicing within the allied health industry, refers to providing more services or more treatments than are clinically necessary for a particular client.

Under-servicing on the other hand, occurs when a client receives fewer services and therefore less care than is clinically required to address their condition, or achieve their mental health or allied health goals. 

Neither of these two are good for the client, and especially for us as allied health professionals, as helpers - our number one motivator, our number one goalpost, our number one guardrail, for what it is we do as helping professionals is to do no harm and is to help the person. Engaging in either of these things are really problematic because if you think about a client clinician relationship, it consists of a potential, perceived, and very real power differential between client and clinician. 

It is really up to us as the clinicians to ensure that neither over nor under-servicing is occurring. We do that by first and foremost, knowing how it happens. So let's have a look at over-servicing. 

Factors Contributing to Over-Servicing

There are a lot of things that can contribute to over-servicing, but if I think about all the many conversations I've had with clinicians over the last 20 plus years, and consider everything that I've read and researched, I am confident when I say that I think there's three main reasons why over-servicing occurs.

#1 - Lack of Clear Treatment Goals

This is when a clinician might set treatment goals when a client first comes in for session one. Maybe they set another couple of treatment goals at session six or even 10. But then, at some point in time, they just stop doing it. Or the treatment goals become really vague, they’re not specific or measurable. What ends up happening is the client just keeps pitching up, and the clinician just keeps doing their thing, but there's no clarity as to what is this destination that the two of us are working towards. 

Unless we know what those treatment goals are, the destination is part of this process. We won't know when we get there, and as a result, we might never get there. At the very least, we need to be able to have a conversation and go, “Alright, we've reached these treatment goals, and now we can make a new decision if something different is required from here on.” So lack of treatment goals is the first thing.

#2 - Misunderstanding Client Needs

I think this is also linked to the lack of treatment goals, is a misunderstanding of the client's needs. I think a lot of times - and we need to be really careful here as clinicians - we might think we know what the client needs, but their needs might be totally different. Some clients are really good at telling us what their needs are, while others are not so good at it, right? 

So it's really important for us as clinicians to ensure that we know what this individual client's needs are. Even if one day you are seeing five clients, and they all have a diagnosis of generalised anxiety disorder, their needs for coming into therapy (as a psychologist I'm speaking) will look different, and therefore their treatment goals will also look different.

Unless we, as clinicians, take responsibility for having that discussion, there is going to be that misunderstanding, and we might just keep on servicing them and the client's needs aren't being met. We need to make sure that we know what those needs are and we service it accordingly. 

#3 - Push to Meet Financial Targets

And then there’s the one that I really don't like, but that often leads to over-servicing is the pressure to meet financial targets. And this can happen in an array of different settings. This can happen in public health, in NGOs, and in private practice. It happens across the industry where a clinician has a set number of billables (i.e. financial targets) that they need to meet on a daily or weekly basis. Let me just say for clarity: there's nothing wrong with having those targets. I'm not saying you shouldn't have them. What I'm saying is where this goes wrong is when over-servicing occurs as a means of achieving those targets. 

For example, instead of the organisation or the business ensuring that this new client flow comes in, what they do is they just keep on churning current clients by over-servicing in order to meet those financials. It's no longer about helping the right clients with the right issues; it's just about seeing clients. That’s a mismatch there that happens. So again, nothing wrong with billables, as a business, you need those and you need targets - that's how you run a business. But you need to ensure that it is achieved in the correct manner, and over-servicing is not the way to do it.

The Risks of Over-Servicing

Needless to say then, over-servicing therefore, can lead to very real and very valid ethical concerns - for us as clinicians, for us as businesses within this field, and for the impact that this can have on clients. It can also lead to financial strain for clients, where clients keep on coming for sessions that they don't need. That is not good. 

Additionally, over-servicing can potentially damage the trust between the clinician and the client, as well as the industry and the client. At some point in time, this client is going to realise that this isn't working, and that's going to have a really detrimental impact on that trust relationship - not just with that individual clinician, but the industry as a whole.

Factors Contributing to Under-Servicing

What about under-servicing? Why does under-servicing happen? 

#1 -A Lack of Thorough Assessment

This generally stems from inadequate assessments, where a client starts with a service provider, they come in and the clinician does a very lukewarm, informal intake. There's no real clarity as to what the client is presenting with.

If we don't know what is going on with this person, we can't help them properly, right? We can't expect the client to come in and just hand over a powerpoint presentation of their life, history, and struggles. No. It is your work as a clinician to ask the right questions, to engage the client, and to build trust and rapport right off the bat so that the client feels comfortable to tell you the things that you need to know in order to do a thorough assessment. 

For clarity, I don't think you necessarily need to do that all in the one first session. Depending on the client and the work you do -  you can be doing that assessment over the first one, two, even three sessions that you're having with this person.

But as the clinician, you need to make it your job, and you need to have a framework that you use to make sure that an adequate assessment has happened. If not, you might help them with A, but you never get to help them with B - which is a real issue because you didn't ask the question. The client might not even know that it's relevant, that it's contributing to A. So that's really important.

#2 - Time Constraints

I've got a lot of examples of this in private practice, but the first one that springs to mind was when I once had a businessman come in to see me for the first appointment. When he booked his appointment, he just said he wanted help with anxiety, and booked the first appointment. Within the first two minutes, he tells me, “Gerda, I need to fly to Sydney for business in two days, and I've got this massive fear of flying. I need to do this as part of my work. I'm already having panic attacks, and I need you to help me because I need to be on a plane in two days time and I've got no idea how to do it.”

It's like, “Yeah, no. I can't help you in the next 50 minutes. I'm fully booked for the rest of the day and tomorrow, and then it's the day you're flying, right? That is real time constraints. So there was under-servicing happening for that client because I could not service his needs in the time constraints that I had.

I've also had people come to me with a fear of public speaking. Again, it was, “I need to do this talk at work in seven days. I don't know what I'm going to do. I can't sleep at night. I'm so stressed about it. I need you to help me.” It's like, I'm booked for the rest of the week. I can't help you in one session. That is real time constraints.

Time constraints can also manifest in terms of the type of funding that clients come in with. For example, if I think about EAP clients and work cover clients, and general insurance clients, we do a lot of those types of work at my practice, we do less EAP work, but we do a lot of work cover and insurance related work, and all those clients come through with time constraints.

These time constraints are often related in terms of the amount of sessions that have been approved under the insurer. So the insurer might say that this person can get five appointments or 10 appointments. Then when we work with this person, we might realise - as we do a more in-depth and thorough assessment -  that they actually need 20 appointments and not 10. But the insurer will say, “No, you only have 10.” So that is a very real and valid time constraint, which often leads to under-servicing. 

#3 - Cost Concerns

This often happens for our private clients as well as our Medicare clients, where the cost of paying out of pocket to see a psychologist, for example, becomes a financial burden for the client. At the time of recording this podcast, Australia is in a period of economic contraction, so people are already thinking twice about what it is that they're doing with their money.  People will always (and they should), prioritise physical needs, utilities such as water, electricity, rent or mortgage, food on the table -  that type of stuff, right? That will always come first, and as a result of that, they will then go, “Okay, so I won't be able to go and see my psychologist or my OT or my speechie this week because I don't have the money to pay for it.” 

So those cost concerns are very real. But on the flip side, that then leads to under-servicing because this client is still not getting the help and the support that they need based on their needs and based on their goals.

The Risks of Under-Servicing

Under-servicing can therefore compromise client outcomes, it prolongs recovery and it negatively impacts the reputation of the clinician as well as the business. 

So, needless to say, both over-servicing and under-servicing is not good for the client. It is not good for the clinician. It's not good for the business, the service or the organisation, and it's not good for the industry. So we do want to avoid either of the two.

Instead, what we want to do is we want to achieve the right balance of service provision. Achieving that balance is going to depend on a number of factors. 

Achieving Balance

First, it needs to be based on the individual needs of that specific client that you are seeing. Then you want to consider the evidence base. In other words, what is the research behind this presenting problem that you're helping this person with?

Then you want to ask yourself: What is best practice for dealing with this specific issue? You also want to ask yourself: What is your theoretical framework, and therefore, the theoretical foundation upon which the way that you work with clients is based?  So there's a lot of factors that need to go into this decision around: What is the right balance for the clients that you are looking after.

I want to take a couple of minutes to share with you the way that I think about this whole concept and how I get to that place of going, “Yes, I am 100% confident that I'm not over servicing this person, and I'm also not under servicing them.” So in order to do that, I'm going to take you back with me many years from now. Many, many years! I'm going to take you back to when I was doing my Masters in Psychology and specifically back to my unit on Health Psychology. I absolutely loved Health Psychology.  So much so that at the end of it, I wanted to become a health psychologist.

That being said, when I did my neuropsychology unit, I wanted to become a neuropsych. When I finished my child psychology unit, I wanted to become a child psychologist. But I think that is a pretty common process that we go through when we are doing our Masters  and we just love every unit. But in terms of my Health Psychology unit, this is one of those defining moments in my learning as a psychology student - fundamental moments in who I became as a clinician as a result of learning this concept. I've continued to use it in my life as a psychologist, and I've always trained my clinical team members in this as well. And that is the term called Salutogenesis.

The Concept of Salutogenesis

Have you heard of that before? Salutogenesis was first coined by a guy named Aaron Antonovsky. He was a medical sociologist and he coined this back in 1979 and he introduced it in his book called ‘Health Stress and Coping’, which was mandatory reading as part of my Master's Course in Health Psychology.

He spoke about this shift from the focus in health research - to move away from what causes disease towards understanding the origins of health and the factors that support it. One of the core principles that he speaks about is the importance of having a sense of coherence . That is each person's ability to really see and view life as, first and foremost, comprehensible; secondly, manageable; and thirdly meaningful. Antonovsky said that those things are key to determining your health and your overall wellbeing. 

In terms of comprehensible; what he meant with that is that life events in your world need to be structured, predictable, and understandable.  When he spoke about manageable; that meant that individuals need to feel that they have the resources at their disposal that will help them to meet their challenges. Then meaningful; is that sense that life is purposeful and that challenges are worth the effort to work towards overcoming.

Having a strong sense of coherence meant that you had those three things, and of course this will manifest at various different levels in each of our worlds. The whole idea was that your health, your wellness and your coping with all of that - will be dependent on those three factors, which forms your sense of coherence.

So that's just a bit of background. But in essence what he says - and what I took away with me from my learning in my masters and brought into my world as a psychologist -  is that he says that health: whether that's physical, mental, or allied health - happens on a continuum.

On the one hand side , if you imagine me drawing a line from left to right here on the left, on the one hand side is disease or dis-ease. That is pathology. You are sick, if it's physical health or if it's a mental health condition, like I'm a psychologist, somebody's stressed, depressed, or anxious, they might do a DAS when they're in disease, and it's like high symptoms, like very severe symptomology. So it's from that end all the way to the other end of the continuum on the right hand side of my line of health-ease. That's where you are healthy. So you are on this continuum from disease or dis-ease to health or health-ease, and then anywhere in between at any point in time.

So if you think about clients coming into your service, they are coming in at various points on this continuum. That means it's really your job to know where they're coming in and to meet them at that point on the continuum. That point on the continuum is going to determine their treatment goals and their specific needs. Therefore, you need to do that adequate assessment at that time to understand what those things are, right?  Then it's our job to meet that person in that place, and then move them along the continuum towards their health goals. 

Now, what often happens is that if I look at more generally the public health system, and when I look at this through the more medical lens - in public health, we know when it comes to mental health, because I'm a psychologist, people that are serviced in the public health system generally have very, very severe symptomology. I don't like using those clinical terms, but I'm using it because I want this to make sense for you. They go in there. A lot of times in private practice we might refer people to public health, and public health will tell us, “No, we can't take on this client because their symptoms aren't severe enough.” They only take really severe symptoms, that’s where people in public health generally start. 

The medical model has been designed in a way where they take people from a place of disease to an absence of symptomology -  which is the middle point of the continuum, okay, that's Antonovsky saying that, not me. So the absence of symptoms is the midpoint of the continuum, and that's the medical model. The medical model says ‘You're coming in with depression, anxiety, stress. We work with you for X amount of time. We do another DAS, depression, anxiety, stress scale, for example. Yeah, your symptoms have decreased. Maybe they're even all in the normal range. Now we discharge you. Off you go and say “Good luck and goodbye.” That's the medical model. 

A lot of people look at that medical model, which is very entrenched in the system and go ‘That's what you need to do.’ And if you do anything above that, you are over-servicing and you are a bad clinician. So I want to challenge that today.

I'm not saying what I've just explained is under-servicing, it most certainly is not. But my point is this, you can choose to have the medical model perspective where you take people from the presence of dis-ease or disease. And in our instance that could be symptoms of depression, anxiety, stress - towards no more symptoms. 

But what about the other half of the continuum? What about where they go from, “Okay, my symptoms are sorted, but I now want to move towards optimal health and wellbeing. Do I not deserve support to get there?” Yes or no? 

The Full Continuum of Care

What we also know is that when clients can move from this midpoint towards health-ease, their sense of coherence drastically improves. What you are doing in the second half of that continuum is working on that comprehensible, manageable, and meaningful life. If you actually support clients successfully during that stage, the chances of relapse decreases significantly. 

In my point of view, that is not over-servicing. What I will say is when the client gets to that point of the absence of symptoms, and we celebrate that in the session with them, it is my job as a clinician to go, “Okay, we've reached the goalpost. You've done amazingly well. Where do you want to go from here? What is it that you want to achieve in your world?”

I see my job as a psychologist not just to help people that are struggling with mental health issues. I have always said that I can take any person off the street - a random person whom I've never met, somebody that has never, ever experienced any mental health symptoms (which don't exist, by the way) - but let's say they did and I brought them into session - I can do six sessions with them, they will pay me money, and they will feel that they are getting value for it, and their world and their life will be better for the skills that they have learned in those sessions. 

Because we can all learn something new. None of us are perfect. None of us have a full set of coping skills. We can all work on our thinking styles, we can all work on our relationships, we can all work on living a better, more purposeful, meaningful life. So I do see it as my job, and I feel like it's my ethical responsibility to tell a client that “We've now gotten from disease from the left to the middle. This is where we're at. These are your options from here. We can now do the following.” And I will tell them about what that is. I will have that discussion in terms of making sure this fits with what their goals are for the next six months, for their world, for their life. What do they want to achieve in their family life at work, in their studies, in their career, right? And I will tell them how I can help. 

Ultimately, it's the client's choice as to whether they want to continue on that next pathway towards increased health-ease, towards having a more meaningful life. And I make it the client's choice, and a lot of clients will choose not to do that. I think a lot of times it's because even clients are very entrenched in the medical models, like, ‘No more symptoms, I'm now fixed. Off I go.’ I hate using that word fixed, because there's nothing wrong with our clients. Our clients aren’t broken. But a lot of times people see themselves like that, and that's part of the work that we need to do.

That's also part of why when I have those conversations, I want to normalise that it is normal to see a psychologist. That you don't have to only see a psychologist when you are in crisis - yes, they're very handy when you are in crisis and when there's challenges that you want to sort out - but they can also help you with that other stuff. Making difficult career decisions, for example, that can really uplift your life from here on.

The thing is this, a lot of people talk about the importance of not over-servicing, particularly in private practice. But I suspect that under-servicing is happening way more than over-servicing - and until you've actually done a deep dive into the numbers around treatment provision, that won't be clear.

A Data Driven Understanding

A couple of years ago, I ran a business conference called Elevate, and one of the amazing speakers that I had as part of that online conference was the fabulous Simon Turmanis from ST&A Psychology in Sydney. He did a talk that was entitled Helping People Well. It was all about client retention and as the title said, it was about retaining clients in order to help them well - not to over-service - but also not to under-service.

I think what sometimes happens is that we are so ethically minded (and I love that about our industry), that we rather err on the side of caution and under-service rather than over-service. I am not saying over-servicing doesn't happen - I'm sure it does, and if it does, you need to call it out. But I have found -  and I speak a lot from a psychological point of view because the majority of people I work with are psychology practice owners. The second biggest group of practice owners I work with are occupational therapists, and then I also work with speech pathology business owners, dieticians, physios, all of the above - so the majority within the world of psychology that I see is under-servicing.

I want to give credit to Simon because I have learned so much from him around those numbers. When he did his talk I clearly remember him talking about a very in-depth meta analysis, and I want to share a couple of those with you. 

What they found was the following:

  • After two sessions, 30% of people would report improved symptomology. 
  • After eight sessions, 53% would improve. 
  • After 26 sessions, 74% had improved symptomology.

But let's go back to the eight sessions. In eight sessions, 53% improved. That is half, just over half (which to me is a scary concept), that only half of the people improved in the first eight appointments. If I look at the retention rates that people tell me their clinicians are achieving, it generally sits around six. If you are listening to this as a psychologist and you go, ‘Oh geez, that's low, my team won't have retention rates of six. I'm sure it's much higher for my team.’ I will encourage you not to assume what your team's retention rates are. 

I would give you homework right now and tell you that you need to go and calculate what that is - for each and every team member. And then I would also look at what is a practice average, because I can tell you for a lot of people it's even less than that. It's very scary when you actually look at the data and then look at research that tells us that people in general are going to need eight sessions for 53% of them to have improved symptoms.

To get that number from 53% to 74%, they're going to need 26 sessions. Very, very interesting. So I suspect, based on a lot of research that I've done - speaking to a lot of people, speaking to a lot of practice owners -  I think there's a lot more under-servicing happening than over-servicing, especially in the psychology part of our industry.

So it's really very important for you to know what those industry benchmarks are. What does the research tell us in terms of how many sessions does somebody need for this specific problem? The research actually differentiates also on another level between acute symptomology, chronic symptoms, and then characterological symptoms, and the amount of sessions required to address each and every one of those types of symptoms - in order for improvement to occur. 

I think for us as psychologists particularly, we don't like looking at these types of numbers, but the thing is that the data needs to inform what it is that you are doing. So if somebody only does four appointments and they really should be doing eight for symptom improvement, based on their presenting problem. Then you need to ask yourself, ‘What is going wrong here?’  That's where that reflective practice comes in.

Putting Client Care at the Forefront

To recap: over-servicing is not good and under-servicing is also not good. 

It is your professional and ethical responsibility to know when your client comes in to see you, where they are sitting on Antonovsky's continuum between dis-ease and health-ease. You need to meet that client where they're at. You need to do a thorough assessment of their needs and their treatment goals.

You need to know who you are as a clinician. You need to know what is the evidence base you need to keep in mind. What is best practice? What are your ethical obligations here, and what is in the best interest for this individual client? You put it through that filter and you go from there. If you follow that, if you act in alignment with that - you will never over-service, but you will also never under-service -  because ultimately everything you need to do needs to be in the best interest of your client. And remember, it is your job to support the client in determining what that is. A lot of clients are good at expressing what it is that they want and need, but some struggle with that. 

Again, you need to meet the client where they're at. You need to help them with that process.  You, as the clinician - with a lot of research behind you and experience - you are also there to guide this client, towards painting that picture for them of what is possible, of what is possible for them. That they are not broken. That they can have a meaningful and purposeful life despite a disability, despite a mental health challenge. That they do not have to be satisfied with mediocre or just with good enough, or just with no more symptoms.

That's not the life I want for myself. That's not the life I want for my kids, my family, my friends and for my clients. So I do see it philosophically and ethically that it's my job to paint that picture of what life could be like for them. And if they want my help to get there, I am with them 100%. I will walk that path with them 100%. And if they choose that now's not the right time, I totally respect and understand that as well. My clients always know that our doors are always open. You can come back at any time in the future and we will be here to help you on that next stage.

And that is where I'm going to leave it for today.

Thank you so very much for tuning in. I hope that was of help. If you've enjoyed it, please do share this podcast with another clinician that you think will find this episode of help. And if you've got an extra minute or two, please drop me a review. I really appreciate it.

Thank you so very much. Have an amazing rest of your day. And as always, remember that I am here to help you build a practice you can't stop smiling about it 🙂


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Gerda Muller

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