The impact of productivity standards on psychotherapy

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It is a Friday afternoon, and you are a licensed mental health clinician working at a non-profit community mental health agency. You continue to stare at your computer screen and start to feel a pit in your stomach grow as you calculate your productivity for the month. Your productivity requirement is 7,200 minutes per month, which roughly translates to 360 minutes per workday. In other words, six hours of your day must be spent in billable face-to-face time with clients. That pit in your stomach turns to dread as you realize you were 420 minutes short of your monthly goal and your program manager gave you a verbal warning for not meeting your productivity goal last month.Psychotherapists are attracted to the field of psychotherapy for various reasons. It could be that a therapist was inspired by psychotherapy that they themselves received in the past. Conversely, a therapist's motivation to enter the profession can be as simple as the desire to help other people in need. Many neophyte therapists enter the field through community mental health agencies and are introduced to a variety of performance standards to quantify their work. This quantification of a therapists' performance at work, usually measured as productivity standards, can lead to less than desired results (Franco 2015;2016) as therapists attempt to cope with the resulting cognitive dissonance as they juggle the quantity versus quality dilemma. Hatchett and Coaston (2018) further added that productivity standards can impact a therapist's job security, which can influence the therapist's decision-making making process in the quantity versus quality dilemma. Additionally, Bennett et al. (2019) assert that productivity standards negatively impact client quality of care.According to Franco (2015;2016), productivity standards are defined as the amount of time that a therapist spends in face-to-face contact with their client. Agencies can, therefore, require their therapist employees to spend a specific number of hours per day in face-to-face contact with clients This is a provisional file, not the final typeset article (Franco, 2016). For example, a community mental health agency can require a therapist to spend 6 to 7 hours seeing clients with the remainder of their time being spent writing notes.A challenge with using productivity standards is that they do not take into consideration whether an employee is satisfied at their work or not (Jenaro, Flores, & Arias, 2007). While there is research available on the relationship between employee measurement and job attitudes (e.g., Böckerman & Ilmakunnas, 2012;Rodriguez et al., 2009a;Rodriguez et al., 2009b), there is limited literature on the relationship between productivity and job satisfaction (Franco, 2015;2016). What little literature there is has found a negative relationship between productivity and job satisfaction as well as a positive relationship between productivity and turnover intent (Franco, 2015;2016).The negative impact of productivity on therapist job outcomes has been discussed (eg. Bennett et al., 2019, Franco, 2015;2016). Franco (2016) concluded that managers and those designing jobs for therapists should consider redesigning jobs that address productivity standards in a manner that reduces the negative impact of productivity on therapist job attitudes. Franco's (2015) finding that job self-efficacy partially mediates the relationship between productivity standards and therapist job satisfaction and turnover intent offers a clue to address this issue.Albert Bandura (1991) conceptualizes self-efficacy as a person's belief in their ability to perform a task and achieve their goal. Using this conceptualization of self-efficacy, one can surmise that a manager can design a therapist's job to increase their self-efficacy towards meeting productivity standards. For example, a clinical supervisor or manager can promote an open environment that encourages dialogue, cooperation, and feedback.Implementing these strategies to increase therapist self-efficacy can lead to increased performance, but it is important to address whether therapist will buy-in to the concept of productivity standards to begin with. During my career as a therapist, clinical supervisor, and clinical director, I have encountered many therapists who struggled with understanding and buying-in to the concept of productivity standards. A common theme that has echoed throughout my conversations with other therapists was that productivity standards did not reflect their performance as a therapist. Creating an open environment for feedback can be an important step in addressing productivity standards, but in order to increase the likelihood of open and honest feedback, a manager or clinical supervisor can start with building rapport with their employees.Rapport-building involves creating a sense of trust between a manager or clinical supervisor and their supervisee through verbal and non-verbal behaviors (Curry et al., 2019). An example of verbal behavior is the use of open-ended questioning (Curry et al. 2019). Clinical supervisors can use verbal behaviors, such as open-ended questioning, to learn about a therapist's perspective on the agency's productivity standards. This, in turn, can enable supervisees to build their self-efficacy (Vandament, Duan, and Li, 2022). As discussed earlier, self-efficacy mediates the relationship between productivity standards and therapist job attitudes, such as turnover intent.Non-verbal communication can also be used by clinical supervisors to build rapport and create a safe environment that promotes dialogue. Examples of non-verbal communication include eye contact, smiling, and leaning forward to show that you are expressing interest (Curry et al., 2019). In addition to verbal communication, non-verbal communication has been found to impact service provider self-efficacy (Mata et al., 2021). A manager or clinical supervisor can use nonverbal communication such as a warm smile and clear eye contact when discussing productivity standards with the therapist. With the help of non-verbal communication and open-ended questions, rapport can be built. Once rapport is built, strategies can be discussed.Clinical supervisors can work towards preparing therapists with strategies to address meeting productivity standards. Supervisors can provide non-judgmental feedback to their therapist supervisees to process the therapist's progress in meeting productivity standards as well as that therapist's thoughts and feelings towards productivity standards. By giving therapists the tools to meet productivity standards and the open environment to process this abstract business concept seemingly unrelated to therapy, clinical supervisors can enable their supervisees to increase their selfefficacy.With all of this being said, rapport-building and enhancing the self-efficacy of mental health clinicians to address the issue of productivity standards may address the issue in the short-term, but perhaps it is the concept of productivity standards themselves that is the main issue. Productivity standards serve as a form of performance measurement (Franco, 2016). Performance measurement is intended to increase employee performance, yet it has been found to have a paradoxical effect on mental health clinicians (Franco, 2015). In other words, instead of therapists increasing their performance to meet an agency's productivity standards, they may become burnt out and suffer from low job satisfaction, which would have the opposite effect (Franco, 2016). They may even be outright fired if they do not meet their productivity quota for the month.Hatchett and Coaston (2018) elaborated on the impact of productivity standards on a therapist's job security and stated that missed appointments from clients can lead to premature termination because it would impact a therapist's productivity. They further stated that both client missed appointments and therapist premature termina

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