Recently I was given a referral for an evaluation, and upon some reflection I declined it. This is not something I am often in the habit of doing, but in this case the evaluation would have involved a clinical situation that did not fit with my integrity. So it got me thinking about the relationship between building your business and professional integrity.
The referral would definitely have been lucrative, and within my scope of experience and skill. And most of us these days certainly cannot afford to turn away business.
Or can we?
If I had taken this evaluation on, I would have most likely have been called on to testify about something that I was not entirely behind. This would have compromised my ability to be an expert witness. As I weighed the pros and cons I was quickly aware of my feeling of “halfheartedness” about the whole thing. And that was what clinched it for me. No patient deserves anything less than a wholehearted therapist as far as I am concerned. And I believe that when we catch ourselves trying to make something “fit” with our practice, we should probably stop right there.
Most of us were trained in clinics or hospital settings where we did not choose our patients. We were there to help everyone, and the idea of a good clinical fit was something we were usually reluctant to give voice to. Social workers in particular are often encouraged to be little mental health Statues of Liberty, treating any of the huddled masses that get sent our way. But no one of us is supposed to treat everyone in my opinion. And believe it or not, there are therapists who want to work with every segment of the population. I have met therapists who love working with borderline personality disorder. Others feel invigorated by working with substance abusers. There are people who really enjoy working with schizophrenia, like me. So in the long run, I think it is important to notice who you like working with, especially if you want to be in private practice.
Being clear on this is hard enough when we are starting or growing our practice. Turning down a referral can be terrifying and guilt-inducing. Somebody needs our help, we need to earn money, and we’re going to decline a referral? Sometimes, yes. Sometimes we need to hold a space open in our practice for a bit. And always the patient deserves a therapist who is 100% committed to the therapeutic relationship. So if we are lucky and have a good coach or supervisor we brave our fears and hold open the space for a while.
But later on in the development of a private practice, you may encounter a slightly different issue, what can be called an “embarrassment of riches.” The phone starts ringing with calls from potential patients, requests for court or special education evaluations, or maybe your old employer wants you to come back and do a workshop for your old agency. It can be tempting to overextend yourself, but I would suggest the following when this happens: Don’t just do something, sit there. Give yourself time to evaluate whether this opportunity is the best opportunity for you after the initial shine or honor of being asked has worn off a little. Because only you know your business plan, and which of the opportunities presenting themselves to you is the best one for furthering your practice.
The picture at the beginning of the blog is what World of Warcraft veterans will recognize as a talent tree. Each character class has three talent trees they can choose from to put their talent points into. The more talents points you put into one tree, the more access you have to higher powers and abilities of a certain kind. At the same time, since you have a finite amount of talent points, putting talent points deep into one tree makes it impossible to put them deep into another. So for example, if I am a mage, I can choose to put my talents in Fire, Frost, or Arcane trees. If I put most of them in fire, I won’t be as powerful when I need to use frost spells.
Sometimes newbie gamers decide to spread their talents across all three trees. They divide up the points and suddenly notice that they are at a high level but aren’t doing that well in the game. At some point someone will notice their talent trees are a mess, and explain to them the importance of specifying their talents. Sometimes therapists do the same thing: We try to be everything to everyone and learn to do a little of this and a little of that. This is often where the diabolical word “eclectic” comes up. We’re not frost mages OR fire mages, instead we’re hurling bolts of lukewarm water, and who needs that really?
If you have been building your practice for a while, you have probably noticed that your phone is starting to ring more, or your website is getting more hits, and this can be so exciting and intoxicating you’ll lose sight of your business plan. This week I had a day like that, where I got 2 referrals for psychotherapy, an extended evaluation, and invited to teach 2 classes! You bet that feels good (and overwhelming!)
But I needed to spend my talent points wisely. If I load up on patients, I won’t have time to do my writing or workshops and ultimately develop passive revenue streams. What’s worse, the patients will get an overworked overtired therapist who is not wholehearted. If I teach two classes, I won’t have enough time to do something else, and if I take on an eval that has me interviewing, writing and expert witnessing, same thing. Time to refer back to my Tweaking 2011 plan. So everything went on hold for a day (remember, we’re running a private practice, not an ER: If something seems so emergent that it can’t wait a day, it may not be something to take on) and I ended up declining half of the embarrassment of riches, offered alternate referrals, and hopefully everyone will be the better for it.
Have you started to specify your talents yet? Have you chosen the talent tree you’ll put the majority of your points in? The secondary one that enhances the first? Does what type of work you accept clearly map to the business plan you’ve made for yourself? I’ve written before about being an Epic Therapist and this is one of the qualities that makes a therapist Epic: Epic therapists specify and hone their talents in one main area. And because they do that they can explain what kind of therapist they are at parties. And they can do solid work and reading in their area so the patient gets excellence. Excellence is what will keep your business afloat in the coming years, so spend your time and talents wisely!
I see private practice following the developmental model. In the beginning there is a lot of experimenting, learning, fear and doubt. As we mature as clinicians and allow ourselves to really know and accept what we are “good” at doing we will look for the right fit. The consequences of not doing this is resentment and boredom.
I keep in mind the law of compensation, when I refer to someone that may be a better fit I can expect another to come along that may be perfect for me.
So young and yet so wise! 🙂
I have read with great interest your article and can not agree with you more. I am not in private practice but often find requests to undertake an intervention does not sit comfortably with my ethos, principles and ethics. I tend to listen to my ‘inner voice’ and as you say, sit with it a while. I am clear about the focus of my interventions and the needs of the client group I work with. As a result, this has led me to decline referrals and provide a clear reason why. To compromise oneself and beliefs is something I have done in the past and hope never to do again!
Hi Linda, yes, I think we’ve all been there, and the payoff is never worth it. Once you commit to being an Epic Therapist, the road gets much narrower.
What a fantastic metaphor – and point – you make about overextension and wholeheartedness. I think that we as therapists are often given the message that we are endless wells of compassion and thus should be able to work with anyone who needs us. But as you state here, that’s unrealistic and potentially dangerous.
Thanks Ashley, the great thing about this metaphor is that we can also use it with our patients who play video games, as a decision-making tool.
Wonderful metaphor! I’m one of those people who finds that many things sound good. Over the years it helped me to recall some words from Stephen Covey: the enemy of the great is the good (I’m sure that I’m paraphrasing). There are many things that we can be good at. But our true talents take us to our own form of greatness and they give us energy, they don’t take it away. Now I will think of them as also being in my Talent Tree. Thanks.
Yes, exactly. I don’t want readers to think that I am talking about “cherry-picking” here, which we hear a lot about with the new health reform changes. I am saying that I truly believe that each of us has different talents and can do excellent work with some folks that others would consider less interesting or rewarding to work with. I think we often feel ashamed of not enjoying working with certain populations, and then imagine that everyone else thinks the same way, so that we will be the noble one and take those. But if we were able to talk with each other more, we’d realize that not everyone thinks like we do, and that would truly allow for diversity in practice.
Great post that really explains the importance of working from your strengths and greatest areas of interest. We just can’t be all things to all people without doing a great disservice to ourselves and those who come to us for help.
Conducting advance research about the skills you want to take and managing it through the skill tree is the basic amongst Role Playing Games especially when 1 skill point really matters. There are several skill tree guide in which standard skills are selected or you may modify them for your own personal use.