Archives for 2011

Ok, so given that I am a therapist and that I blog you might think the answer to this question is “Yes.”  But it isn’t, at least not a simple yes.

In the course of my work with coaching clients and scouring the internet for blogs, I have seen what I think works, and what I think doesn’t.  But first, let’s examine your motives for blogging (how therapisty is that?)

Do you want to blog to:

• Get out a message you feel passionate about?
• Promote your practice?
• Disseminate information on a topic?
• Give your patients some part of you and your work together to hold onto between sessions?
• Generate discussion with your colleagues?
• Vent about your day/life/work?

If you answered yes to one or more of those then blogging may be a good way to do that, with the exception of the last one.  And if the only reason you want to blog is because you want to promote your work, that is probably not sufficient.  Let’s address these exceptions one at a time.

Vent-blogging

This form of blogging can occur on a dedicated blog site of your own or on a Facebook page.  Since the entries are time-stamped there is no real confidentiality to them if you blog immediately after some frustrating occurrence happens with a friend/partner/child/patient.  If you are blogging on your own site you could make it private by moderator approval, but that doesn’t guarantee that one of your subscribees won’t cut and paste something you said and send it out into the cyberverse.

That is not to say that blogging about your work or a patient is inherently wrong, or venting.  There is a difference between exploring a clinical issue and your thoughts and feelings around it, and venting about a patient.  An excellent example of this is a recent series done by Jason Mihalko on dealing with a patient’s suicide.  The series is a very respectful and candid exploration of the aftermath of a suicide, and as such is both sophisticated and useful to his colleagues.  While I wouldn’t feel comfortable writing that sort of blog post, I am very glad that Jason takes that risk, and I think psychotherapists and their patients will benefit from it.

The main point is that Jason is not using his blog to sound off or vent.  This is a far cry from what you see on Facebook or in posts that say, “Just finished with my OCD patient, boy does she drive me nuts.”

Self-promoblogs

Anyone who has read previous posts of mine will know that I come out swinging whenever therapists “accuse” me or other colleagues of promoting our work, as if it was a crime.  Our field has always done self-promotion:  Writing an article for a journal is promoting your work.  Sitting on a panel of experts is promoting your work.  Giving a free talk is promoting your practice.  There is nothing wrong with self-promotion.

Unless it is without any content.  The problem with self-promoblogs is that they aren’t really adding any value to the reader, they’re just an infomercial for your practice.  So if the only reason you are considering blogging is because you or a coach told you you need to have a presence on the internet, please don’t.  Wait until you find your passion in the work, or it will show.  And if you don’t know what your passion is in your work yet, than you need to back up a few steps before gracing the blogosphere with your presence.

Presence is Personal

Successful bloggers and therapists have at least one thing in common, personal presence.  People don’t want to go to a therapist who acts like a robot or has no particular style.  And people don’t want to read a blog that lacks a sense that there is a human being behind it.

Look, there are a whole lot of people out there in the world who need your help.  But the world doesn’t need another Jason Mihalko or Susan Giurleo or Mike Langlois, they need you.  What issues, which populations motivate you the most?  For me it is gamers and technology, but if I were asked to blog about eating disorders I’d run out of steam fast.  Not my passion.  But fortunately there are others out there for whom it is, and if you are one of them you could probably talk about eating disorders for hours on end.  And if you can talk about something meaningfully for hours on end, that is a good indication that you could blog about it.

In the end, blogging and being a therapist have some common traits.  You need to know yourself, or at least be far along in the process of getting to know yourself.  You need to have some area of expertise, something you feel competent in.  And you need to have some personal presence that makes a patient want to work with you instead of someone else, or read your posts instead of someone else’s.

True Colors, Please

Last but not least, if you want to blog I suggest you adopt an attitude of radical transparency, meaning write each post with the attitude that it will be read by everyone:  colleagues, patients, Aunt Ethel, everyone.  If you aren’t comfortable putting something in a blog that might be read by everyone, don’t put it in there.  Because I can tell you from experience that friends, colleagues, patients, and family members who I never even told I had a blog have read mine.

Hopefully I haven’t scared any potential bloggers off.  Because blogging as a therapist can be very rewarding.  I have met colleagues and had opportunities that I never would have had if I didn’t blog.  Blogging has helped me build my coaching practice.  It has helped grow the number of public speaking engagements I have, and gotten me invited to new venues as well.  Blogging has brought me new friends, new patients and new clients.  It’s put me in the path of some of the most innovative thinkers and doers in our field.

Most important, blogging has helped me get out the message that we need to rethink the way we understand video games and treat the people who play them.  So if you’re wondering if blogging is worthwhile, it is.

And if you have something to say, I say go for it!

If you are considering blogging and want some help focusing and getting yourself up and running, I’m offering a webinar on Wednesday, November 30th from 7:00-8:00 EST.  For more info you can email me at mike@mikelanglois.com

Recently, a coaching client of mine told me this story. She was amongst therapist colleagues, and they were congratulating her on how well her practice was growing. She thanked them, but said part of the credit was due to the coaching and consulting she was doing with me. She was very surprised at the negative and critical responses she got from them after they heard that. She wondered why people are so down on working with someone to grow their practice or modernize it with technology.

Although I was not surprised by this response, it is something I have wondered myself from time to time. Here are some of the reasons I have noticed, along with my translations:

• “I’m too old to learn about technology.” AKA, “I have internalized ageism and am now using it to assert that I no longer am required to learn anything new.”

• “My practice is doing fine just the way it is.”  AKA, “Although I have noticed a decline in my referrals I will continue to assert that it is insurance, the government, or patient resistance that is to blame, not my disinterest in change.”

• “I can’t afford to pay for supervision, coaching or consulting.”  AKA, “I have decided that supervision, coaching, or consulting is optional rather than integral to starting a therapy business. I have furthermore planned to launch or grow my business without having an operating budget.”

• “I don’t have time to make an appointment with a coach, consultant or supervisor.”  AKA “my unwritten business plan (because I didn’t have time write it) is that I plan to rent out someone’s office for 4 hours a week and market in my spare time.”

• “Those people who do coaching are only in it for the money.” AKA, “Despite my clinical training which taught me to see global thinking and negative attributions about people as a sign of pathology, I have decided that these people are one-dimensional. Furthermore, I am hoping that I can split off that part of me that wants to make money doing therapy while at the same time make money.”

• “I can get everything I need from my peer supervision group, and it is free.” AKA, “I truly believe that by surrounding myself with others who are trying to build up their practice, I will get lots of referrals (thus eliminating the need for a business plan) even though this group is least likely to give away referrals because they too are trying to build up their practice. Besides, I find our shared complaints about the field comforting.”

• “Ok, I know I should hire a coach, consultant, or supervisor, but I am afraid to take the plunge.” AKA, “Despite what I have learned about insight being necessary but insufficient for change, I’m going to express my feelings and hope that that ‘counts’ as change, and take that insight as the goal rather than the starting point.”

Part of what I am gunning against here is the surrounding of oneself with internal and external naysayers. Julia Cameron, author of the Writer’s Way, talks about crazy-makers, and I think that naysayers are a particular type of crazy-maker.  Naysayers operate solidly from within the depressive stance.  These are the folks that say you can’t make it in private practice, or that it is harder nowadays, and that things aren’t the way they used to be.  Take a good look at them before you buy into it: Do you really want to take pointers from someone with a failing business?

Yes, things are different nowadays.  And in many ways that’s a good thing.  Health Care Reform is going to provide more people with more coverage for mental illness than ever before.  But my prediction is that it will be a two-tiered system, where insurance pays for symptom reduction and chronic mental health conditions for the most part.  Therapy for insight, relationship improvement and quality of life issues will become more and more private pay, and/or more and more time limited if insurance does cover it.  Hey, wait Mike, aren’t you being a naysayer here?

I don’t think so, because I think that both parts of the system will have places for therapists.  I think that people who want to work primarily in a medical model will find they have a steady flow of brief episodic treatments, and folks that want to work in a private model will have a vibrant practice if they set it up like a business.  If anything, the only people I think who are getting short shrift here are the poor, whom our government will treat as if they have no inner world.  But therapists will have plenty of opportunities.  If you work for them.  What will change is this idea that getting into telephone books and on insurance panels is the extent of the work you need to do.  And that in many ways is what people are complaining about.

If you want to be in private practice full time and make $200 an hour, I have no problem with that.  Unless your business plan is to sit in your office like a film noir gumshoe with your feet on the desk.  Nope, for top dollar you’d better be generating content outside the therapy hour, whether it be a book, podcast, video or workshops.  That will be how people can determine “why you?” and that will be what sets you apart from the legions of gumshoes who are sitting in their offices waiting for the phone to ring, or commiserating in groups.

Am I saying you should hire me?  Not necessarily.  In fact, if this post annoys you you definitely shouldn’t, because this is my style and modus operandi.  I give away a lot of free content, but I’m not gilding lilies.  What I am saying is hire someone, after you do some research.  Look into a person’s recommendations on LinkedIn or their website.  Follow them on Twitter for a while.  Look at their online and offline content to be sure they are more than hype.  But then take the plunge, and invest in your business, i.e., pay someone.  And if a colleague of yours says they are working with a coach, applaud their initiative rather than criticize them.

There are plenty of reasons people don’t hire a consultant, coach or supervisor, but I have yet to hear a good one.

Like this post? You can work with me too. 

There’s more where that came from, for only $2.99 you can buy my book. I can rant in person too, check out the Press Kit for Public Speaking info.

My therapy practice is located midway between Harvard and MIT, and this is deliberate:  There is a high-density population of neurotics, including yours truly. 🙂  And the past two weeks, pivoting on Labor Day, have brought the changes that come with a community so academic.  The curmudgeon in me notices that parking spaces have vanished, the lines at Starbucks have grown longer, and there are more disoriented people walking around asking for directions.

But on a good day I can notice something different, the excitement and exploration as new students from around the world begin a new year and perhaps a new phase of their lives.  There is an eagerness and optimism and curiosity that I see in the nonvirtual world that reminds me that it’s about time, and actually the perfect time to talk about patches.

Most Massively Multiplayer Online games are initially released with all the content a player needs to get started and have hours of enjoyment playing the game.  But like other art forms, the audience of video games enjoy continuity and variety.  Many art forms account for this:  Books and Movies have sequels, music has follow-up albums, and video games have patches.

Patches are downloaded from the internet by the user and patched into the existing game content.  They are used by the game developers to add or change existing content.  Originally used mainly to fix bugs, they have since evolved to include downloading large amounts of new content for the video game.  They can change the entire landscape of the game world, like WoW’s recent Cataclysm did (gamers bear with me, I know that Cata is technically an expansion pack) add abilities or game modes (cooperative play) for players.

Patches (and expansion packs) are a big deal in the gamer community.  The release dates are sometimes announced, often rumored, and always anticipated.  Discussion abounds about what new things are coming:  Will we now be able to fly?  What kind of new instances are going to be in the game?  Did you hear that the entire region of Thousand Needles is going to be flooded?  The night of releases the servers are taxed with people that are updating their versions of the game.  And when it hits, people spend hours exploring and enjoying the game with renewed interest in vigor.

Back to School, Back to Work

Did your heart fall a little reading that phrase?  Back to school has a very depressing air about it, back as if we’re backsliding, going back to something we were trying to escape.  Back to work, too, has the sour taste of ended vacations to it, picking up where we left of in our daily chores. Therapists ruefully notice this as a bit of job security:  The phone suddenly starts ringing again as our business swells from the misery and dissatisfaction of others.  Here in New England, back to school/work dovetails perfectly with the weather and our Puritan heritage:  Work, for the night is coming, work for the end draws nigh.

But what if we took a page from the gamers’ book here?  What if it wasn’t “back to work/school,” but instead the release of a new patch?  How much more exciting and interesting would that be, if we had just finished downloading Patch version 9.10.11?  We might be more like those students in my neighborhood:  Not disoriented but exploring, not clueless but curious, not in the way but blazing trails, not taking up space but staking new territory?

I often write about why therapists should learn more about video games for the sake of providing better treatment to their patients who game.  But this post is specifically for everyone to learn from gamers.  Educators, why not think of this as a new patch release rather than “another” year.  What if we viewed education through that game lens?  New content has been released in the world, how can you patch it into your classroom or lecture?  Therapists, rather than look at this as the time of year where business picks up, why not look for the new content that has been released in your field? (Ok, that’s too good an opportunity for me to pass up: For only $2.99 you can buy my book and integrate gamer-affirmative concepts into your treatment.  🙂 )  And if you’re not a therapist or an educator, how can you shift your mindset from “back to work” to “new patch is out!”

Remember how I mentioned that one of the early and primary roles of a game patch was to fix bugs?  Well, what kind of glitches does your life or work have?  Have you spent sometime thinking about what could fix it?  Why wait until New Years to change something?  You will enjoy the content of your life more if you take some time to fix X rather than working around it for another year or decade?

And what new content do you want in your life?  There’s a lot you can add.  There’s a lot you can remove too.  This year I removed the content of teaching one class because I wasn’t enjoying teaching it.  I added the content of writing a couple of books and doing out-of-state speaking, because I like traveling and love talking about video games and therapy.  Do you want to grow your practice, start a blog, tweak your website, or present?  Write that down in your practice patch notes.

Look, I know it’s tempting to do nothing but sigh with relief that your kids are out of the house, or mourn the passing of summer, or grit your teeth and get back to the grind (and getting TMJ!)  But how about doing it differently this time?  How about opting for an attitude of curiosity and eagerness  instead?

One thing most patches come with is “patch notes” which tell the gamer what’s new, fixed or changed.  It can be the mechanics of a certain class (Mages now have improved Scorch) or new loot that drops.  Why not take 20 minutes and write your own patch notes?  What about your class (career) mechanics do you want changed?  Do you want imroved EMDR skills?  Write that down, and enroll in a course.  Do you want to fix that rug in your living room that you always trip over?  Write that fix down?  Do you want new content in your job?  Write that down, and ask your boss for something new to try out?  Do you want new content in your life at home?  Write down what kind it is (I suggest getting a new dog from Petfinder.)

If you are in a relationship, write note with your partner(s) about what needs fixing, what new content you want.  Families can use this as an opportunity to meet and write down some patch notes for their family.  This is especially useful if you have gamers in your family! Who wants to go over house rules whne you can discuss the latest patch release of Family version 9.10.11?

If you don’t want to write stuff down, no worries, you can try the idea out anyway.  Are you willing to try for one day, one hour, to look at your life as if it was a new release rather than the same old content?

In Buddhism, one of the “Three Jewels” of Buddha is the Dharma.  One way of understanding the Dharma is the enlightened state of realizing the teachings of Buddha.  When you have the dharma, you are “awake.”  This very moment, you are mindful and aware. You may not have been the last moment, and you may not be the next moment, but right now you are awake, and that means everything.  So if you read this post, right now, for just this moment, you are aware that you have a choice:  You can see the next days of your life as being stuck in the same old routine of back to work; or the moment Patch Version 9.10.11 comes out.  Not wouldn’t that be interesting?  New content, new fixes to old problems.

This post is done, I wonder what you’ll do?

Like this post?  There’s more where that came from, for only $2.99 you can buy my book.

There is a stereotype that exists that all gamers are isolated, lonely and depressed.  Too often therapists just assume that, almost to treating gaming as a symptom of depression if not addiction.  I have written at length about this elsewhere, but today I wanted to address the suboptimal treatment that can come from assuming gamers are not lonely, isolated or depressed.  I hope that this post will also be of benefit to gamers as well.

The 21st century video game is inherently social.  In fact, the recent boom we are seeing as Facebook, Google+ and other social media networks rush to integrate gaming into their platforms stems from the recognition that video games can be very powerful media of connection and engagement.

This isn’t really new, even Atari’s Pong had two-player mode.  And not all games are multiplayer, but multiplayer has become more and more predominant and accepted in mainstream culture.  But this is all in a way of saying that video games are social media, and in many ways, group activities.  Halo night is not unlike poker night, raiding takes place in real time with people talking with each other, and being in a guild can be a deep and abiding group membership that lasts for years.

Now when you are sitting with a patient, one of the things you often do is assess for engagement.  Do they still go to poker night?  Are they attending AA meetings?  Have they been enjoying the touch football group they joined last month?  And if they reply in the negative that should set off some alarms, or at least invite curiousity as to what’s changed.  Isolation is a key component of depression, both as a symptom but also as a precipitant and cause of it.  It’s why we often work with patients to become involved in community in some way.

Unfortunately, if therapists don’t see gaming as a community activity, they may miss early signs of isolation and depression.  They’re not spending as much time “on the computer,” so what?  Isn’t that a good thing?

No, it’s not necessarily a good thing.

I hope gamers will read and weigh in on this, but here’s my take.  Especially in multiplayer games, changes in enjoyment or activity can be a sign of emotional upset.  You’re just not getting the same sense of enjoyment from the game, or your guild.  People seem less connected in-world, more irritable, and Ventrilo has more arguments or awkward silences.  Or maybe people are rage-quitting more often, or a clique has formed and you aren’t in it.  Sometimes, often, guilds dissolve or reconstitute over this, and the player feels disillusioned.  And when this happens the gamer can turn to the gaming stigma from the “real” world and say, “these weren’t real relationships, they weren’t important.”

One thing that can happen is that gamers gquit (guild quit) at this point, and decide to do solo questing.  If there is a new patch or content they may enjoy this, or going over the old familiar instances at a higher level to farm may be fun.  But suddenly the game isn’t “fun” any more, and a feeling of numbness and ennui settles on the player.

At this point the simplest and most fundamentalist attitude is to blame the game, or oneself as “addicted,” but I think in many cases the truth is more complicated.  Detached from her in-game community the gamer may begin to feel isolated, bereft and yes, depressed, just like many of us are when we lose a social outlet.  But therapists and gamers may have a harder time catching it than if the social activity is one more socially sanctioned, like touch football or going to church.

Video games are social media and they can meet many social needs.  If you are a gamer and the above description fits you, ask yourself if maybe the problem is a social or psychological one.  Could your lack of interest in video games be a sign of a lack of interest in pleasurable activities?  Could your isolation be what’s causing the game to be less fun?  Is it time to consider risking the effort of joining a new guild, transferring to a server that seems more friendly, or help noobs level up and begin a chat or two?  I do not think video games (or any technology for that matter) is inherently bad, but I do think our personal issues and emotional concerns can play out in any arena, and that includes the game world.

So if you’re a therapist and you’ve been trying to be gamer-affirmative, don’t take a naive approach.  Don’t assume that things are hunky-dory in the player’s gaming, ask them about it.  Assess their in-world activities and level of enjoyment just as you would scrutinize their other group activities.  And be prepared to understand that decreased enjoyment and participation in their games of choice may actually be a sign of increased depression.

All of this is not to say that there is something wrong with people who play solo video games or even solo in multiplayer worlds.  That would be like saying that reading a book is pathological unless you read it in the library among others or join a book discussion group.  What I am saying is that video games are not, should not be exempt from our scrutiny, and that a gamer-affirmative therapist will explore these topics with their patients.  And patients should report changes in their gaming experience just like they should any other changes that impact they’re mood and sociability.

P.S.  Those of you who read regularly may have noticed that I took the last 2 weeks off.  I was on vacation and writing my book.  It’s now out on Amazon and other eBook stores for the scandalously low price of $2.99, so go buy it!  🙂

Prologue

It is a breezy warm July night here at the Secret Headquarters.  Boo and I have opened up the outdoor deck, which is complete with zero gravity chairs, and we can hear the wind rustling through the big tree in the front yard.  Every now and then a neighbor walks by on the street, and the open windows carry the sounds of summer from other houses, where lights are starting to go on one by one.  Looking up I can still see the clouds drifting across the sky, but now the moon has risen, and it’s definitely dusk.  Boo is stretched out looking over the area the SHQ overlooks, and keeping an eye on EVERYTHING.  Moments like this I often feel incredibly grateful for the life that I’ve ended up with, a comfortable meaningful life for the most part, with a career I love and family and friends of several species.  And often with the gratitude comes this moment of incredulity when I remember my past and I think, “How did I ever get here?”

Past As Prologue

Shakespeare’s famous line from The Tempest is one Freud was surely inspired by:

Whereof what’s past is prologue, what to come
In yours and my discharge.

The Tempest, act II, scene i, lines 253–54

Freud may have disagreed with the second half, which speaks clearly against psychological determinism.  But he surely would agree that the past is what informs our life and experience.  Each of us carries within us a history of the world we have inhabited since our existence began, and although we read and study about history that predates us, that will always be after the fact of us, and secondary to our experience.  It is in the past, but it will never be in the past of us.

I have a not-so-friendly academic rivalry with a colleague at a university where I teach Psychodynamic Theory.  When I proposed a second course to teach more contemporary psychodynamic theory, she almost single-handedly opposed it, and when it was approved despite her lobbying she began to talk with the faculty about retiring the first course.  Who needs that classic stuff?  She teaches a course on treatment that several of my students have taken, and when she discusses the concept of the assumptions underlying each therapist’s theory and practice she says to them, “I wonder what assumptions Mike Langlois has underlying his work?”

I doubt she’ll ever ask me directly, but if she does I think my reply would be that my assumption in how I think about and do therapy is “What’s past is prologue, what to come in yours and my discharge.”

The Importance of Lore

The video games I have always been the most a fan of always have lore.  World of Warcraft is one notable example.  The world of Azeroth, introduced to us during the early video games Warcraft, Warcraft II and III, had a history and mythology spanning millennia before it ever arrived online.  And what an amazing testimony to the human mind and creativity, that housed in servers and beamed across the computers of over 12 million people a world was created and then co-created that spans planets and eons!

In a recent episode of Doctor Who, the TARDIS, the Doctor’s craft that travels through time and space looking like a police telephone box on the outside while being infinitely large inside, has its consciousness stolen from the ship and implanted in the body of a human being.  For the first time, the Doctor (and we) get to hear its point of view.  Shortly after being downloaded into the human, the TARDIS says to the Doctor, “Are all human beings like this?  They’re so much bigger on the inside!”

I guess that would be a second assumption underpinning my work, that human beings are so much bigger on the inside.

Gamers are often huge fans of the lore behind the video games they play.  People often don’t understand the time, depth and complexity of such lore.  But take a look at WoWWiki, which is 0ver 91,000 pages long, which gamers have researched, compiled and written to deepen the experience of the game and help the WoW community out.  To give perspective, Shakespeare’s First Folio containing 36 of his plays was about 900 pages long, and this pdf of Freud’s Complete Psychological Works is 5081 pages.  That’s a lot of time and effort that has gone into writing about one video game.  And although Rift’s Telarapedia is much smaller at 4,041 articles, it is growing steadily.

Therapists, especially psychodynamic therapists, have historically appreciated the power of the individual’s history and the psychic mythology that evolves from it.  In fact, that sentence, with it’s fusion of history, mythology, and evolution, encapsulates in many ways the way we understand the human mental world.  So why is it, when we as a profession appreciate the symbol sets that accompany dreams, metaphors and mythology, that we fail to question our gamer patients about the lore surrounding the particular games they play.  I have found that for every gamer I ask who says they aren’t really “into the lore,” there are two who will with increasing excitement talk about the histories of Azeroth, Hyrule, or Middle Earth.  And listening to the stories of epic wars begun from the most minute of disagreements, or betrayals by family members, or forbidden monsters that were unwittingly unleashed and devastated the world as it was once known, what therapist can fail to hear the resonance in the lives of their patients?

All Roads Are Now Bent

As a child I read Tolkien with great joy, but it wasn’t until I was a young adult that I discovered that the entire Lord of The Rings, epic though it was, was merely a pale epilogue to the Silmarillon.  For those of you who have tried to read the Silmarillion and failed, I encourage you to persevere, because it tells the story of the world that became buried under the one Frodo and company trod upon.  The lore of the earlier world in the Silmarillion included the creation of the Valar (“Powers”) by the god Illuvatr, the introduction of evil into that world, and a battle between gods that spread to the races created by them, including elves and men.  The end of this story includes the sinking of the city of Numenor after its last arrogant king seeks to find the Blessed Land of Aman:

“But Ilъvatar showed forth his power, and he changed the fashion of the world; and a great chasm opened in the sea between Nъmenor and the Deathless Lands, and the waters flowed down into it, and the noise and smoke of the cataracts went up to heaven, and the world was shaken…But the land of Aman and Eressлa of the Eldar were taken away and removed beyond the reach of Men for ever…For it was nigh to the east of the great rift, and its foundations were overturned, and it fell and went down into darkness, and is no more. And there is not now upon Earth any place abiding where the memory of a time without evil is preserved.”

The story ends with Illuvatr changing the shape of the world, which was initially flat, and bending it so that the “Straight Way” to paradise is lost:

“Thus it was that great mariners among them would still search the empty seas, hoping to come…to see a vision of things that were. But they found it not. And those that sailed far came only to the new lands, and found them like to the old lands, and subject to death. And those that sailed furthest set but a girdle about the Earth and returned weary at last to the place of their beginning; and they said:
‘All roads are now bent.'”

Psychotherapy occurs then in this sadder time, when “there is not now upon Earth any place abiding where the memory of a time without evil is preserved.”  All the roads are now bent, and our patients come to us troubled by this fallen world they now live in.  Sometimes there is not even a glimpse in consciousness of what has been lost, just the unconscious conviction that it has to still be there, somewhere.  History has been altered around them, so that it seems that there has never been a different way to live, and all we have to guide us in the treatment is the mythology that remains.

My bias to both gamers and therapists is to say, “pay attention to the lore.”  The lore is important.  In video games lore is what holds the fabric of the world together, or in the case of WoW, what explains the Cataclysm when Deathwing erupts from the depths of the world to tear it apart.  The lore is what happened before the Rifts opened in Telara, how the Triforce came to Hyrule, and what caused the wicked god Malpercio to destroy the world in Baten Kaitos.  In therapy we have to ask the question, “how did I get here?”  How did it come to pass that the world was forever changed, paradise lost, and yet I am still here to mourn it? What happens next?

That as Shakespeare said, is in yours and my discharge.  Do we give up, and live in the mythology?  Or do we mourn the passing of a world so we can move on?  Gamers know that endurance and learning from past battles is important.  Therapists understand that those who do not learn from their history are doomed to repeat it.

Good therapy and good video games both involve the gradual solution of a mystery. This is not necessarily the same as winning or symptom reduction, but is ontologically more satisfying.  As the fortune teller in Baten Kaitos says, “Someday you will know, who you really are.”  We will understand the meaning of the lore of our lives, and how it has deepened, but not ultimately defined us.

Portal 2 is an ingenious game with a pretty simple goal:  Figure out how to get from point A to point B.  Ok, so maybe the game, and plot, are a little more complicated than that.  Your character wakes up in the labyrinthian depths of Aperture Industries, now in ruins and abandoned.  Except for a homicidal robot who remembers how you tried to destroy her (in the original game) and plans to return the favor.

For the majority of the game (maybe all of it, I haven’t finished it yet) you don’t know what happened to the people who worked at Aperture.  Everything, the offices, the jargon of the old CEOs recorded voice, is circa the late 1950s-early 1960s.  There are a couple of exceptions, the killer robot GlaDOS, another robot who tries to help you escape, and a wormhole gun.

The wormhole gun is where things get really interesting.  You can shoot two different color wormholes, orange and blue, which connect each other no matter where or how far apart they are.  This effectively allows you to teleport from one part of each room to the other, or teleport tools you need from one place to another.  In some cases there’s a dripping pipe that needs the liquid rerouted through a wormhole to come out somewhere different, or a block that needs to be transported to a lever to hold it down so you can exit the room.  You don’t really die in the game, just return to the last puzzle you were working on.  And so it is that Portal 2 hinges on the ability to analyze the game environment, think in terms of cause and effect, plan a sequence of events, and rethink failed combinations.  In other words, Portal 2 is about problem-solving.

What if our educational system was like that?  No, not in terms of homicidal robots.  But what if, as Seth Priebatsch presented at SXSW, we had a better-designed game?  The current educational system still encourages rote learning over problem-solving, individual work over cooperative goals, and standardized testing like our MCAS over the portfolio option.  In fact, when I was working in school systems more directly, the portfolio option was only considered for students who had been identified as learning disabled.  Students would spend weeks being taught to the test, because student performance evidenced teacher performance evidenced school performance.  The stress level of teachers and students was palpable.  Even in Gr. 4 the kids were picking up on it, and by high school those that still managed to be invested in this educational model made themselves sick in those weeks of testing.  Even the most animated and creative of classes became rows of quietly scribbling individuals trying to regurgitate what the state had determined they needed to know.

People who live outside of the day-to-day experience of public schools may have no clue how Orwellian education has become.  Year after year we see creativity drummed out of students and teachers alike, through no fault of their own.  Administrators become increasingly embattled as well, with test scores putting their jobs on the line.  The images in Portal 2 of rows of office desks with rotary phones have become a chilling metaphor for where our educational system is headed if we continue to focus on grading rather than progress, individual memorization over group problem-solving.  I have seen elementary schools remove recess periods to spend more “time on learning,” thereby depriving many children the one safe place they have to play in their city, and an important milieu to learn social skills.  In high school, parents continue to push their children into Honors and AP classes and emphasize grade point averages in order to get into the “right” school, and an entire industry called the College Board has sprung up to encourage this with SATs, prep courses, handbooks on writing the college essay and “more great products.”

What if progress was really leveling up? What if you completed tasks and solved problems, got a reward or achievement badge, and unlocked a new level.  This is very different than sitting in one “grade” for 180 days and then advancing for time spent there.  But that is what effectively happens in schools.  Retention is rarely considered a good option for a number of reasons, and kids are pushed through.  What would it look like if students stayed with their teachers or group until they were ready to unlock another level, and motivated to do it?  In Portal 2 there is an overarching storyline that unfolds as you progress, a mystery to solve.  Why can’t we have some similar mystery to progress through in school, some storyline other than “to get into a good college” or “to get a good job?”  Is it any wonder why our children are often identified with behavioral difficulties or social skills deficits?  They’re bored and frustrated!

And what if cheating weren’t cheating? Why is it in the age of Google we still artificially force children to cram in and rely on information only in their heads?  And what is wrong with children copying from each other, with working in a group and helping each other?  When was the last day you went to work and didn’t allow yourself to get help from a co-worker, calculator, website or an answer that was not “in your head?”  Cheating is directly tied to trust and fun, any gamer knows that.  If the game is fun and the rules are clear, and people are given the option to work together and at their own pace, I predict you’ll see a lot less cheating.  I did get stuck in Portal 2 a few times, and truth be told I looked up the solutions on the web, but most of the time I wanted to succeed within the unnecessary obstacles of the game mechanics, and I turned off the solution video the instant the immediate problem was solved so as not to “spoil” the game.  If we can begin to present education as more intrinsically rewarding, we will see a lot more persistence.  And if we can begin to present learning as group problem-solving we will see a lot more trust and teamwork, which will set kids up for succeeding in a global Web 2.0 world.

Psychotherapists are often uniquely positioned to help with this, but many of us have not embraced the technology and mindset to do this.  We continue to set up sticker charts and give out stars when we could be using Chore Wars or the WoW Achievement Generator.  We could educate teachers and parents about the amazing work John Lester is doing which can allow virtual field trips to explore learning about Paris or the Orbiter Shuttle.  We could help adolescent patients problem-solve and learn how to use Facebook to enhance their social skills or use Twitter for school projects.  We could model taking learning out of the classroom by taking therapy out of the office sometimes, using Skype to get a tour of where the patient lives.

Last month I did a learning exercise on Twitter, called the “DBTgame.”  For one day I tweeted every hour an exercise and it looked like this:

One of the cool things about social media for me has been the way it has allowed me to connect with other therapists.  I’ve tweeted articles and humor with some.  I’ve explored the worlds of Telara and Azeroth with others.  I’ve had dinner in Laguna Beach with colleagues I’d only met before on Facebook.  I’ve had both fun and networked, and I’ve learned that not only can networking be fun, but that experiencing that social form of fun makes for better and more productive networking. I’ve had invitations to travel and do workshops, requests for supervision, interviews, and dessert, entirely due to social media.  Yes, dessert.

One promising first step I’ve seen therapists take is LinkedIn. When I first joined LinkedIn, there were only a handful of psychotherapists using it.  Now there are thousands.  LinkedIn seemed to be a safe entry point into Web 2.0 for my colleagues, because it focussed on the “professional” aspects of their human being and online presence.

And then things got stuck. And here’s why.

Psychotherapists in private practice are a lot like old-school kindergarden teachers.  You know, the ones who always kept their class doors closed, parents and administrators out, and carved out their own space and laws of physics.  We push ourselves through grad school, work for years in public settings, and then finally we strike out on our own to build our private practice.  And boy do we take the private part seriously!  Not in the way I wish we did, as in a privately-owned and privately-held business concern, but as a top secret laboratory where we practice our craft shrouded in mystery.

Private practice psychotherapy has become, and maybe always was, not unlike feudal Europe in the Middle Ages.  We each have our own little barony with rules and culture, and we rarely talk to each other.  And the common idea bandied about is that “psychotherapy is a lonely profession,” as if that is a necessary evil rather than a potential occupational hazard.  Many people try to deal with this by joining professional organizations, attending workshops, and supervision groups.  And these are useful for our professional development, so when we burn out we can be up to date on the latest in the field that has driven us crazy.

In short, we are afraid to be social in a more personal way beyond the safety of professional boundaries.  And one of the biggest concerns I hear about social media is the danger of crossing boundaries from professional to personal.  I think in fact that when people talk about being afraid of social media technology they are as afraid of the “social” part as they are the “technology” part.

The term “boundaries” is perhaps one of the most misused and misunderstood terms in psychotherapy.  Yes boundaries are important things.  France has a boundary, as does Germany.  That doesn’t mean no one from France should ever go to Germany and vice verse!  You don’t usually hear U.S. citizens saying, “I wanted to go to the Winter Olympics in Canada, but that would be crossing a boundary so I can’t.”  We have gotten this bizarre idea in our heads that transgression is equal to violation, rather than a word for the concept of crossing over.  If you’re house is on fire you better be prepared to transgress your door threshold, or you’re going to experience another kind of burn-out.

Therapists need to learn how to have some permeability in our boundaries, and technology can help break down our social isolation from our colleagues.  One great example of this is Twitter.  Twitter is designed for short bursts of dialogue, which is excellent for me when I want to have a little social connection in the 15 mins between patients.  I may not have a chance for a cup of coffee with my friend Susan, but I can send her a Youtube video spoofing Adele and Angry Birds.  And the only reason I know that Susan would enjoy this is because she allows herself to disclose on Twitter that she enjoys the music of Adele.  She did that some time ago, and from what I can tell no ethics charges have been brought against her from disclosing that.

Disclosure is another word that gets misused by the way.  Our patients have suspected that we are humans for some time, and if they follow our Tweets and find out that I am enjoying Portal 2 that may mean something to them about my humanity.  But it is not the same as mooning someone in my office, and it is time we understood the difference.  The first humanizes me, the second is inappropriate.  But using social media is not some sort of inevitable slippery slope towards debasing myself and violating someone else.  That is just a thought we use to terrorize ourselves into solitude.

Gamers have understood the importance of socializing for years, despite the stereotypes we level against them for being asocial.  Guilds are an excellent example of this.  For those who aren’t in the know, guilds are voluntary groups of players who join up with each other in the game world.  There are raiding guilds that focus mostly on progressing in the game, casual guilds that balance progress with more fun and social activity, and a variety of degrees between the two.  And through the use of Ventrilo and other software, people can actually talk and listen to each other as they play.  One of my fondest guild memories is a Christmas party we had in Dun Morogh.  Dozens of players in our guild, from all over the US, UK and Australia showed up at a frozen lake for a guild picture and dancing around a bonfire.  There were snowball fights, there was a gift exchange, virtual mead was drunk.  It was a blast.  And this social activity strengthened our bond as a guild and I think improved our ability to play together as well.

And yesterday and today on Twitter I have been joking about our forming a posse of therapists.  I think everyone needs a good posse, partners in crime to plot world domination with.  We need to have some playful interactions with colleagues if we want to succeed in our professional lives.  At least I think we do, and I’m not going to refer anyone to see a dour therapist.  So good business networking is personal as well as professional.  You can take your work seriously, but if the only way you have of interacting with people is serious and somber, sign up with the Pilgrims.

Epic therapists need a guild. We can’t solo quest forever.  We need to share with each other the victories and the setbacks in our businesses, not maintain this constant pokerface to give the impression that we have the perfect, full private practice.  Who are people you can brag to safely? Who are the people you can tell when you’ve had a slowdown in referrals and are afraid?  Who can you talk to when you need to be challenged to rethink how you’re doing things?  For me, those people are the people that I can also laugh with, play with, and meet for coffee.  If you are carrying around your office in your life and bearing outside the office, I’m not going to want to connect with you that much.  Learn to shift gears.  Try lurking online, share a link on Facebook that you found meaningful.  Comment on other people’s blogs even if you don’t have one of your own.  It’s good business to be human, and it’s often fun as well.  What kind of guild would you like to join?

True confessions, this weekend I am hard at working playing Portal 2, Rift, and Air Penguin for iPhone.  Have I mentioned lately how much I love my job?  🙂

So for this post I wanted to direct you to a recent interview I did with Yahoo!  Although the title “Tips for Overcoming Online Gaming” puts a slightly negative slant on gaming, I was really appreciative of how Jaleh Weber did not edit me to keep with that slant, but rather presented my ideas as pro-gaming.  In other words, they let me say what I thought and believed, rather than what may garnered interest.  Traditionally, media has tended to hype the potential negative aspects of gaming, and view playing as an epidemic of addiction, which anyone who has ever read a post of mine know is NOT how I see gaming.

Still, I do think that sometimes gamers want to moderate their playing time, and address the concerns of friends and family, so I did offer a couple of tips.  I hope you will check out the interview if you want to have my perspective in a nutshell.  Please feel free to pass it along any which way you can, and if you want to quote it, just let me know so we keep information and integrity happily wed.

Here’s the article, bon voyage!

A comment on an earlier post expressed the hope that I would at some point talk about the practical ways therapists might use social media with their patients in treatment.  I realize that I had not made a connection explicit yet in this blog.

Video games are a form of social media.

When we say social media a lot of us think Facebook or Twitter.  But the Web 2.o world is a lot more social and interactive than that.  Whenever you play Scrabble with friends on Facebook, post your high score on a leaderboard, help a friend complete something on Farmville, or create a platoon for Call of Duty, you are engaging with social media.  Perhaps it is because we have begun to take social media more seriously more quickly than video games that we overlook this.  So although I will at some point discuss ways to use Facebook, Twitter, etc. therapeutically, let’s start with video games.

One of the most fun and pervasive parts of various games is “unlocking” an achievement.  That usually happens when you complete a task that is spectacular in its rarity, or epically mundane.  One example is the fishing achievement in WoW of “Turtles All The Way Down.”  This is the achievement of catching a Giant Sea Turtle mount while you are fishing.  The chances of doing that on each cast is pretty low, so this usually consists of fishing up hundreds of fish over a long period of time before it happens.  Then all of a sudden it there’s a burst of light on your screen, and a little achievement sign pops up with some music to tell you that you’ve accomplished Turtles All The Way Down.  You get the reward of a turtle mount, and the achievement goes on your achievement log for all to see.  Grats!

Therapists with a pathologizing stance will be inclined to think, “Wow, what a waste of this patient’s time.  No wonder they can’t lose that 40 pounds or clean up their laundry or make dinner for their spouse.”  At best they’ll hold this judgment in, and at worst they’ll say something like “Do you think that this is the best way to use your time given the problems you’ve mentioned in here.”

A gamer-affirmative therapist, on the other hand, can try this approach:

“Congratulations, that must have taken a lot of time to complete.  It also shows us that you have the capacity to stick with tasks that may be pretty boring, let’s see how we could use that to your advantage outside of the game as well.”

Okay, so just how can the therapist do that?

First, you need to acknowledge to yourself and to the patient the reality that real life is often a lot less stimulating than games when it comes to tasks.  We all do mundane tasks every day (or avoid them) and no lights or music comes up, and we don’t get a prize.  And we live in a very puritanical culture which steps up to the plate and says, “Just so.  Virtue is its own reward.  Work, for the night is coming.  Work, for the end draws nigh.”

Nah.

I remember working in an urban school district and going into the lunch room, and borrowing a trick I learned from Loretta Laroche.  Several of my friends and colleagues were already sitting at the table eating, and I said, “Excuse me please, I have an announcement to make.”  (If you have never tried that part, do it!  You get to make announcements, you’re allowed.  It is SO cool.)  They looked up at me.

“I didn’t have to come in today.  I could have stayed home instead.  But I did, and I worked very hard this morning, and I would like a standing ovation.”

They burst into immediate applause.  And that was it, I got my standing ovation, felt great, we all laughed and the day got even better.

You can make real life look more fun and shiny in the mundane spots.  And bear in mind that this is for the rough spots.  I am NOT saying that I’d rather log on to Second Life and see a simulated version of the Himalayas if I was offered an all-expense paid trip to Tibet.  Remember that we’re talking about our patients’ challenges here.  Doing laundry IS boring.  Exercising or dieting is long and often tedious, and unless you love cooking and have plenty of time, making dinner isn’t always that fun either.

So what does this have to do with social media and using achievements therapeutically?

Well, there is great website to help you do this called the World of Warcraft Achievement Generator.  It lets you create your own achievement banners, and gives you the opportunity to send the link, or the actual picture.  So for example if you are working with a school-anxiety or absenteeism issue with a middle school child, you can plan out what they need to do for what kind of achievement.  Say they are having trouble getting to school on time.  You set the goal of getting to school on time once this week.  When they do, they or their parent emails you to turn in that quest, and they get an email back from you which says this:

For those of us that recall the gold star on the chart, the principal behind this shouldn’t be revolutionary.  But we hesitate to use the technology to gamify therapy.  And this is not just behavioral reinforcement, this is social.  The child or parent emails us, expressing pride in an accomplishment, and we email something back that hopefully conveys something about who we and they are, and mirrors their achievement.

Therapists who work with adults can use the concept of achievements as well.  Patients who are trying to lose weight can engage their partner or a supportive friend to generate the achievement banners that the patient plans out with you in treatment.  In the case of weight loss they might have achievements for eating smaller portions, adding veggies, or losing a certain amount of weight.  Once they do one they receive this:

Note that you can integrate this with Weight Watchers or other token economies.

Often patients need some help breaking down seemingly insurmountable tasks into manageable chunks.  So to win the Title Achievement of Master Launderer you may help them do this in session, and create smaller achievements as they work towards their title, like:

Detractors may think that this is too facile, that life doesn’t work that way.

But it can.

There is no harm in providing enriched stimulation to motivate a patient.  Let’s face it, you probably wouldn’t go to work for too long if you never got paid.  And you earn those achievement points we call “vacation days” too.  We need to get over this puritanical idea that we’re either supposed to love work with all its drudgery, or that having fun is not the point.  What if having fun is the point, or at least one of them?

So games are social media, and game concepts can be used therapeutically.  One example of using gaming and technology is the achievement generator.  Can you think of others?

P.S.  Yes, there is a way to gamify the goal of having your partner cook dinner.  The non-cooking partner takes a lesson from Iron Chef and picks 2-3 “secret ingredients.”  The cooking partner than has to come up with a meal based on those ingredients with what you have in the kitchen.  Good Luck!

So here we are!  New Blogsite, new title, and even more fun and interaction!  I hope you noticed the little bar at the bottom of the blog when you got here.  That bar, by BigDoor, is the first step in gamifying this blog.  You will see on your right the leader board, which shows you your experience points, recent achievements and awards.  If you log in to Facebook you’ll unlock another achievement, and if you share posts, comment or come back regularly there’s not telling what will happen next!  If you are coming here from the old blog, please take a second to subscribe to the new one, because in a little while the old blog will stop posting.

Like many of my posts, I can only take partial credit for this one.  I can’t tell you where the lion’s share of the credit should go, because as I mentioned before I never talk about patients online.  What I can say is that this post is one of the reasons I so enjoy working with gamers.  Gamers are extremely creative, whether they believe it or not, and I learn so much about how to integrate gaming into my work from them!

World of Warcraft, especially when you begin to play, uses a lot of quests.  A quest begins when you see a non-player (robot) character with a yellow “!” on her head.  Upon clicking the NPC, a scroll appears giving you the option to accept the quest, telling you the backstory of it, and what your reward for completion will be.  You complete the quest, and when you come back the “!” has become a “?” and you turn in the quest and get your reward.

There is a specific form of quest called the escort quest.  To complete the escort quest you have to walk with the character a certain distance and protect them from whatever monsters may pop out.  So for example you see a night-elf in a cage with a “!” and when you talk to her she says something like “thank you for freeing me, let’s get out of this cave!”  You walk alongside her as she makes her way to safety, at which point she thanks you and rewards you with loot.

Therapy is an escort quest in many ways.  We meet the patient where they are stuck, and we walk alongside them as they struggle through their life for a time.  We try to help them face whatever monsters pop out on the way.  And hopefully at some point, they get where they need to go, and we collect our loot.  If the escort quest of therapy goes well, the patient ends up in a more rewarding place, and the therapist gets the reward of a job well-done and some money.  If the escort quest does not go well, we try again, or the patient looks for another therapist better-geared to help them complete their quest.

The term non-player character is misleading, because it may give the therapist a false sense of importance and focus.  It is the non-player character that is in the midst of their story, trapped in their history and circumstances.  We are the interlopers, hopefully helpful interlopers, but interlopers nonetheless.  The patient will one day leave our office and walk away from us back into their world with all it’s epic mythology.  The fact that they disappear from our lives doesn’t mean that it was all about us, it means it is time for us to find another person with a “!” on their head.

Therapists can learn a lot from the concept of the escort quest, but patients can too.  This concept can be extremely useful in couples therapy.  Often we find that one member of a couple overfunctions and another underfunctions.  The overfunctioning one may try to goad or encourage, cajol or threaten the underfunctioning one into change.  The underfunctioning one may feel increased resentment and anxiety, and hunker down in their stuckness.  Anyone who has ever been in couples therapy has probably seen this on either side of the therapy chair.

When one member of the couple brings up a problem, the therapist can ask them, “is this an escort quest?”  In other words, who owns this problem, who has the agency to do something about it, and who doesn’t.  Sometimes it is an escort quest, such as making plans to have a family.  Sometimes it is not an escort quest, such as one person getting sober or finding a job.  It is important to know when a quest is solo and act accordingly.  Gamer couples can use this idea themselves and gently remind each other that this is or is not an escort quest.

Other examples can include overbearing parents who hover over their adolescents while they do their homework and call their teachers in a rage when their child gets a B in AP Science.  Your child’s education is ultimately not an escort quest. And with adolescents, good parenting requires the acceptance that more and more quests are solo quests, however much we may wish they weren’t.  Trust me, you’ll appreciate this later when you do not have your 37 year-old child living at home unemployed.  And if they do end up in that situation, it still isn’t too late to remind them and yourself that their life is not an escort quest, and help them launch.

Lastly, there is the example of hospice.  My experience working with death and dying has shown me that hospice work is in many ways an escort quest.  A patient’s dying and death is their own, but we can walk alongside them on the way.  This sort of escort quest is a very powerful one, and the feelings when that quest is completed and the patient goes onward alone can be extremely poignant.  We are reminded that we were an important but minor participant in the patient’s life.  One of the best analogies of this is embodied in the final clip of the Return of the King (I recommend you watch on mute, the song ruins it if you don’t):

http://www.youtube.com/watch?v=uzxgaDDiuxc

Take a look at your life, your relationships, or your practice:  What are escort quests?  What aren’t?  In a real sense, becoming able to distinguish between what is and isn’t an escort quest IS the reward.

A lot of things can be done to communicate your interest or openness to working with patients who game simply by adding some things to your waiting room and therapy office.  Watch this for some examples:

Lately I’ve been speaking about Epic Therapists and some of the qualities they have.  I’ll be doing more of that in the future, but I wanted to discuss today the concepts of gearing up and raids as they apply to your practice.

Why do gamers try and fail and try and fail and try when they raid?  To feel the optimism Jane MacGonigal refers to in her book “Reality is Broken,” is one.  The loot is another.  Loot often consists of higher level “gear,” armor and weapons than you already have.  So the idea of gearing-up is to fight harder and harder bosses to gear you up so you can see the higher level game content.

Players can’t fight those higher monsters alone, so they participate in Raids.  Raids are groups of 5, 10 or 25 players who choose to group up so that they can explore the higher level dungeons, defeat the more powerful bosses, and share the loot.  For raids to be successful the individual players need to be able to learn from each other, know what their job is, strategize, and get along.  When I first starting playing my mage, a wizard-type character with weak armor, I didn’t understand that my role wasn’t to get close to the boss, so I’d run in and start attacking the boss up close and get killed instantly.  Over time and with the help of other raid members I learned that the role of the mage is to run away from big things, hide, and shoot very dangerous spells from a great distance.

Once gamers can do that, they begin to be aware that each boss has a different strategy, and they begin to talk, think and plan with other raid members how best to defeat it.  And people listen, think and perform best when they are feeling a sense of camaraderie rather than a sense of hostility.  So often if a player is nasty or selfish they won’t be invited to raid with a group.  So if you want to get geared up, you need to be a team player.  You need to commit to work with others for hours at a time, do your research, strategize, and play nice and fair.

So what can therapists learn from gamers?

1.  Commit to Work with Others

Therapists have been notorious loners in many ways.  Once we get into private practice we are often very isolated, and when we meet up with our colleagues we often don’t engage with them as members of the same team.  There is a certain amount of oneupsmanship and caginess that I have often experienced.  An example of this is how there are times when everyone I meet has a practice that is full and going well.  Business is booming, and yet, at the end of the conversation I or my colleague will mention casually that we “still have a few openings,” available and are accepting referrals.

Come on.

First let’s ask all of those private practice folks who are full up to stop reading, because you really don’t need to hear anything else that’s coming up, given you have a flourishing business.  So go have a coffee or something.

Ok, for those of you who are still here, let’s get real for a second, you and I.  We’re not full up, we just don’t want to sound like we are empty.  Of course we want to keep getting referrals, and even if we are busy for the next couple of weeks we may have a suggestion about who else could see the person.  And we’re not alone, or else why would there be all of these workshops and consultants (including yours truly) offering to help us learn how to grow our practice?  Nope, we may have a full schedule for the week, but if someone were to give us a referral, we’d probably take it if the patient sounded like a good fit.

Look, health care reform is heating up, and we are undergeared.  We therapists need to get a raid mentality.  We need to find and connect with our peers and have a sense of community.  We need to network and reach out and get to know each other.  To do that we need to be honest with ourselves and others, and let each other know when we have openings and not posture like we’re the next Freud.  We’re not, our business will ebb and flow and there are lots of therapists out there, so to grow and have a flourishing practice means we’ll always need to acknowledge that we could cultivate more business.

2.  Know Your Class

What are your talents and abilities?  Who do you work well with?  If you tell me that you like to work with everyone I will never EVER refer to you.  Promise.  I do not believe that a therapist can excel in treating every age group and every diagnosis.  I don’t refer to Jacks-of-All-Trades-and-Masters-of-None, because there are too many excellent therapists out there I meet and know who are Masters-of-a-Few-or-One. And the same applies for me:  If you are looking for a gamer-affirmative therapist, an LGBT therapist, or an adolescent therapist who does psychodynamic therapy, I’m your guy.  If you are looking for an expert in DBT or CBT, it is not me.  If you are looking for an expert in geriatrics, I do not have that expertise.  And if you are looking for someone who is good with “trauma, anxiety or depression,” I can take your referral, but there are probably 500 other people who are able to work with that vague population.

Now that you know your class, get to know the class of others.  That way when someone wants to refer someone to you for EMDR, you can recommend a good colleague, and you’ll probably get future referrals because you were helpful to boot.

3. Do Your Research

Epic therapists are always researching what they need to learn to get better geared to do therapy.  For me getting geared up means regular supervision with someone I trust, an ongoing peer group or class such as the MIP Fellowship, reading articles recommended to me, keeping an eye on Twitter, reading KevinMD.com, having coffee with colleagues, downloading and playing free trials of video games, going on Harvard Med Schools eCommons for current articles, and reading Hendrik Hertzberg in the New Yorker every chance I get.  Yes that’s a lot of work, but notice how much of it can be social in nature.  And really, so much of it can be fun too!

Another great way to do your research is to teach a workshop.  Few things clarify and educate me the same way that preparing a workshop for my grad students or colleagues does.  If you can’t think of what you could offer a talk on, please go back to number 2.

4.  Strategize, strategize, strategize

Health care reform is on the way.  It is ramping up in MA already, with our Governor’s push to have MA lead in reform.  ACOs are being developed.  The insurance companies are strategizing how to maintain their profitability.  Our second and third largest announced a merger this week.  Our professional groups are strategizing to have a place at the table when it comes to legislating.  Some providers are forming ACOs or trying to, because they realize that whoever gets there first has an edge.  Protesters are strategizing as well.  Those of us in solo or small practices need to get our raid group ready, and to do that we need to strategize:  What do we need to do to support our patients? What’s our business plan?  How can we help each other?  This is something you hear my colleagues Susan Giurleo and Juliet Austin talking about a lot, and for good reason.  We are about to see a seismic shift in how we can make money as therapists, and without a strategy we are going to “wipe,” as the say in WoW.

5. Play Nice and Fair

Things are about to get a lot more competitive out there, but they don’t have to get adversarial.  There are lots of people to help, lots of ways to do it, and we have our fellow raid members to help us.  Share those referrals with the colleagues in your raid.  Write emails introducing them and their specialties to your referral sources.  Pay it forward by helping them publicize their work and workshops.  Take one out to coffee when s/he is having a hard day.  Listen to their challenges, and talk about yours.  I firmly believe that the more authentic and supportive you are to your colleagues, the better it is for the whole raid.

As gamers say when their raid is about to rush into battle, “Incoming!”  We are about to engage in perhaps the biggest battle to maintain our businesses and protect the work we do with our patients.  None of us will be able to fight those battles alone.  If you are in it for the win, group up!