The other day I tried to refer someone to my colleague Susan Giurleo and she said no.  In the process I got to learn more about what she focuses on, and I was reminded that I never wrote this post.  So here goes..

I say no to a lot of referrals.  It’s easier to do that with a full practice, but I used to do this even when I was starting out.  Here’s why:

1. In life and work I try to face my fear. 

Like most people, I have had adversity in my life, and one thing I have learned is that I am my best self when I am not thinking or acting out of fear.  When I first started my practice I just wanted referrals.  Heck, I just wanted the phone to ring.  And I noticed that.  I realized that I was about to recreate a fear-based work environment similar to one I’d just left.  And hadn’t I turned down some interviews and a job offer because I wanted to go into business?  I needed to calm down and not get desperate.  Nobody wants a desperate therapist.

I also knew that if I became focused solely on filling up my office hours I’d have a harder time setting limits on what I did in therapy.  In fact that would in my opinion contaminate the treatment relationship, because I’d be worrying that patients would leave rather than paying attention to them, and avoiding difficult conversations because I didn’t want to “lose them” and lose money.  If I wasn’t able to contain or face my anxiety, how could I help anyone else contain or face theirs?

2. I’m a good enough therapist to not try to be good enough for everyone.

When I was in grad school, it was the perfect storm.  As students, we social workers had it drilled into our heads that we had to help everyone.  This was a natural fit with my yearning to help everyone that I came into contact with, in order to prove I was good at what I did.  Remember the phrase “a Jack of all trades is a master of none?”  That’s where I’d be if I kept on the road if my ego and my grad school had held sway.

But after a short amount of time I realized that there was plenty of work to go around, AND that different people enjoyed working with different types of patients.  So now I am confident enough to know that I can do the work and enjoy it.

3. I’m an excellent therapist with some patients.

After a few years, I had done enough good work, and enough medicore work, to begin to notice when I was doing excellent work.  I do good enough work with couples, depression and anxiety.  I do mediocre work with eating disorders drug addiction and alcoholism.  Where I am an Epic Therapist is with gamers, geeks, LGBT individuals, adolescents and trauma.

By saying this I am not diminishing any of the issues or groups I am less than Epic with.  Nor am I trying to say I am the best therapist in the world, there are lots of people who do just as good or better treatment than I do.  What I am saying is that I am a specialist and a thought leader in very specific niche, that’s what makes me Epic.  Think of what that work is for you, and that will be what makes you Epic.

Since I do the traditional 45-50 min psychotherapy hour, and since I need to sleep sometimes, I can only see a finite number of patients in a week.  Saying no to referrals allows me to continue providing therapy at the most optimal level, and I can honestly say that my work is often enjoyable and always gratifying and meaningful.

4.  Saying no to referrals allows me to have a socially just practice.  Let’s talk money for a minute.  After all, that’s one of if not the main reason one wants a full practice, to make money.  I need to make a certain amount of it to support my family and contribute to our household.  But I have always been clear that I want a diverse practice, and that includes working with low-income patients.  So I always have a certain number of hours that I offer PB+5 or 10 appointments.  In order to provide those I need to be thoughtful about the patients I begin working with for reasons financial as well as clinical.  This means being thoughtful about referrals for reasons financial as well as clinical, and that means saying no to referrals.

5. Saying no can be a networking opportunity.

When I don’t take a referral, I usually try to make a referral for the caller.  Just because I say no to a referral doesn’t mean I can’t be useful in recommending someone else.  This keeps me engaged with my colleagues and understanding who might be a good referral for any given person.  I can be more informative than a list from an HMO, and hopefully it gives a more educated referral for the person.

This is also good business, because it helps me continue to talk with my peers about who they enjoy working with, and what their expertise is.  It also has generated more informed referrals for me, both for patients and supervisees.

So these are some of the reasons I often say no to new referrals:  To say no to fear, to stay clear with myself about my strengths and weaknesses, to do the best clinical work, make enough money to do pro bono work, and to be a part of a professional network.  It’s OK to say no to referrals, even when you’re starting out.  Especially when you’re starting out.

Several times a month I get calls from prospective patients contacting me to provide psychological testing. Problem is, I don’t do psychological testing. Not my training, not my technology, and last but not least not my interest. But nevertheless every month I get calls.

I get these calls from students at a local college, who were referred to me by student support services, and I know exactly who is referring them to me. I know because back when I was building my practice, I marketed heavily to people in the education field, because of my background in providing psychotherapy for people with learning differences. I clearly made a good impression, because the referrals keep coming, and there are lots of other people out there who could be getting them. This is an example of what I call a pipeline from Rhode Island.

Imagine if you will how much oil gets piped from Alaska to refineries, probably a lot. Because Alaska is sitting on a lot of oil resources. Now imagine how much oil would get pumped to an oil refinery from the pipeline if it was from Rhode Island. Not a lot. Little Rhody has a lot of resources if you want music (Newport Folk Festival) or it’s top export, waste and scrap gold but oil doesn’t run strong in the Ocean State.

A pipeline doesn’t do you much good if you don’t have the resources that are being looked for by those coming down the pipeline. This is an example of a mistake I made early on in building my practice that hopefully you won’t make. You see, I just wasn’t clear enough on what I had to offer potential patients. I was more focussed on getting my name and number out there, and rattling off my condensed version of my CV. So through no fault of their own, people heard, “Hi I’m Mike Langlois… Psychotherapy … Experience with Learning Disabilities … ADHD … School functioning…” and filled in the blanks.  I now have this great pipeline from a local college that consistenly feeds me absolutely zero referrals that I can use!

This was reflective of a few problems I’d had back then:

1. Starting a business is not like applying for a job. I was still in the frame of mind that my CV was the touchstone for presenting myself professionally. My soundbite was there a compression of that, rather than focussing in what my ideal patient and expertise is. This was because I was used to applying for a job, having an interview with an agency, and trying to explain how I could do excellent work with every patient in their demographic.  Yet this one-size-fits all approach was exactly why I wanted to run my own practice!  So although I was marketing my practice, I was presenting as a job applicant.  To be fair I was trying to present a niche rather than the generic “I work with people who have anxiety and depression,” but I could have done a better job of conveying what kind of work I do, which brings us to the next problem.

2. Not everyone knows what psychotherapy is! You may have noticed that people think social workers take children from homes, psychologists prescribe medications, psychiatrists ONLY prescribe medications, psychoanalysts do Rorschach tests, or any other number of nuggets of misinformation floating around out there. So even if you are clear on what you like to do or who you enjoy working with, it pays to be specific about what you do. Just a few examples:

“I evaluate children to see if medication can support their learning.”

“I do talk therapy with people who have trouble being happy in relationships.”

“I provide psychological testing to help people identify learning disabilities.”

“I testify as an expert witness about the mental and social functioning of families and their individual members.”

3. Don’t just “say” you have a niche, don’t be afraid to want a niche. Like many people I have consulted with since, I was giving some lip service to having a niche but really was afraid to have one. As a result I would water down my explanation of who I was and what I could do so that I could have a broader “appeal.” Trust me, there are plenty of people out there to help, we can be specific in who we want to work with. And it makes it easier for colleagues to refer to you specifically. We have been conditioned by decades of managed care to think our major qualifications are “I take X insurance,” and “I’m .75 miles from the patient’s work/home.”  Those are not your major selling points. So ask yourself again, who do I want to work with?

Bottom line? Take time figuring out who you really want to work with, and then when you are presenting yourself in the community stick with that. Insurance companies will feed you the people who are looking for a .75 mile away therapist (and many of these will turn out to be great referrals even though not necessarily the best reason,) so with your own marketing be more picky.  One of the great things about reading this blog is that it hopefully gives you a chance to avoid making some of the same misconnected pipelines that I did when I was getting started.  One of the great things about writing it is that I get to research the top export of Little Rhody. Now if someone ever needs scrap gold I won’t send them to Alaska…

Many of my colleagues in the psychotherapy profession get that social media is here to stay, and a force of nature in the lives of our patients.  Therapists have grown more accustomed to listening to recorded arguments on smartphones, getting introduced to patient’s Facebook pages, and watching patients thumbtype texts in sessions.  And whether we have accounts or not, most clinicians have at least heard of Twitter, Facebook, and other forms of social media.  But in terms of our own practices, what good can social media be to therapists?

At least when it comes to therapists, we aren’t so excited by bells, beeps and whistles.  We didn’t gravitate to a job that usually involves 2 people, 2 chairs (or a couch and a chair,) 4 walls and a door.  That therapy space was chosen by us and subsequently shapes us.  We choose it for many reasons: shyness, preference for intimate one-on-one relationships, privacy, and stripping down human relationships to their essentials so we can focus on them.  And we often become shaped into more private, more independent, less tolerant of distraction, and more habitual people as a result.  If any of you are like me you may have noticed that when you meet a friend for coffee you begin to get antsy 45-50 minutes into the chat.  I’ve hung out with therapist friends and we both wind down the conversation at the 50 minute mark without even thinking about it!

In short, we aren’t inclined to immediately warm to the social aspects of social media.  We’re less than dazzled by the wide and sweeping networks of connections we can make all over the world, and multiple instant messages from several different people pinging us every minute or so doesn’t thrill us.  In fact, we often make the judgment that we prefer narrow depth in our relating to wide “shallowness.”  And truth to tell we’re a bit snooty.  I’ve had colleagues criticize some of the sites and blog posts I have recommended to readers merely because they aren’t “vetted” by a group of our peers:  They would rather trust the judgment of 12 folks with degrees on a committee somewhere than someone with unknown credentials.  This isn’t wrong necessarily, but it is limiting.  And it slows down the flow of information.

A growing number of us are choosing to differ with, or at least diversify from, that prevailing sentiment.  We’ve realized that Twitter can be a powerful, economic, and rapid way of sharing new articles, recent studies, upcoming workshops, and sometimes even snippets of those workshops!  Links to speakers, presentations and findings are being tweeted more and more from therapists who are interested in research and dissemination of knowledge.

In addition, private practitioners are finding ways to leverage social media to market their practice, reach more people and grow both their sphere of influence and their business.  This is an exhilarating and accelerating time for our work in this regard!  Technology has enabled us to be more social in our business than ever before in history.

But none of this makes social media powerful in ways that therapists care about much of the time, and this weekend I was reminded of what the true power of social media has for us.

The power of social media for therapists and therapy is not that it is social by nature, but that it has the potential to be personal.

I had forgotten this, as I sometimes do, in my zeal and excitement with the technology and its reach and speed.  Those of you who have followed these posts or attended my workshops are no stranger to my enthusiasm for social media.  This past month I had used the social media of Twitter, Facebook, YouTube, blogging and Constant Contact to pull together a workshop on video games and psychotherapy.  I credit the power of social media in helping me market and get a great group for this workshop.  And then social media bit me in the behind.

I had sent out my latest newsletter and was starting to get responses from various articles.  Now most of these responses are usually positive, but in the mix this time was a very angry and negative one from a recent workshop attendee.  It was actually more than negative, it was what I would consider my first real attacking hate email.  Needless to say I was disturbed and unhappy to read it.  After reading it I sent out this Tweet:

@MikeLICSW :  Eek. Just got my first hate email from someone who had actually said she really enjoyed my workshop. Guess she changed her mind. #ouch

I put down my iPhone and got ready to do some other work, when seconds it pinged, TWICE:

@susangiurleo:  @MikeLICSW Hate mail means you’re doing something right…*high five* : )

and

@Leilanimitchel :  ‘interesting’ – wonder whats going on for her – might not be about you of course!!

Leave it to my colleagues to help me reframe and regain some perspective on the hate email.  But what was even more striking was the personal feeling of warmth I experienced to get two thoughtful and caring responses seconds after my post.

The Power of Social Media in Therapy is the Personal.

This truth is something I have known for several years.  We learned it at Sparta Networks a long time ago and in the same way.  Initially when we began our company we were in love with the technology of social media.  We loved coming up with new functionality and features!  We’d actually spend hours playing with different ones–one of my favorites was our birthday reminder feature, which we were using way before people began to track their friends birthdays via Facebook.  Our feature not only sent you a reminder, but put a little birthday candle next to your avatar.  Boy did we geek out about that stuff, and sometimes still do.

But that ultimately wasn’t what grew our company the most.  What ended up being the most important aspects of social networking solutions at Sparta were the personal elements.  One example was our long and ongoing conversations with each client who wanted personal customization (i.e., all of them 🙂 )  These people needed to engage in a personal conversation with us to feel understood uniquely about what their business was trying to achieve.  We ended up spending much more time on consulting and education around social media than if we’d just been cranking out one boxed software product.

And often we didn’t just develop the social media network for them, but engaged in creating the sense of community that makes social media work, brick by personal brick.  For example, if we were doing a social network to support the product testing of a certain big food manufacturer, we needed to participate regularly with other members of the social network.  At first again we thought the majority of this would be systems administration stuff in the form of bug reports or permissions.  Again we were wrong.  That was a part of it, but if we didn’t engage in a personal way with each member of the group and start off conversations or games the network wouldn’t take off.  A successful launch of a social media site requires both a certain social critical mass and a focussed personal engagement with each member by other members.  At least that has been our company’s experience, and continues to be part of our consultancy component at Sparta.

This is the part that therapists need to get, the part I have alluded to in previous posts about gamers.  The power of social media in therapy is the personal. It is getting those caring Tweets from real people and real friends.  It is the use of social media like Facebook, Twitter, and blogs to reach out person to person to convey “Hey, I understand you.”  We all need to feel known deeply and meaningfully by others, one relationship at a time.  When therapists critique the technology as shallow and superficial, they are in some ways correct.  But they are usually looking at it from the outside in, rather than having the subjective experience of warmth and recognition by the Other that social media has the capacity to convey.

The truth is that social media technology is by nature social, but by potential personal.  The social nature of these technologies is much more easily understood from the “outside in” than the potential personal capacity of it.  For that you need to be within it.  Even listening to your patients speak about it won’t quite do it; because at best you have to make an effort to imagine yourself into their experience, and at worst you make the empathic failure of dismissing their real emotional experiences within the social media and virtual world.

So if you have been reluctant to engage in social media on a personal level, please give it a try.  I think you’ll discover and experience real feelings in real time if you do, and that is what I believe ultimately powers good therapy or good social media.  What do you think?

A lot of my colleagues complain about not being able to build up their practice. I don’t get it. I am usually as booked as I want to be, and the phone rings pretty much daily. But when I talk to colleagues, I often begin to glean why they might have a difficult time getting their practice full. They don’t want to do anything outside of the therapy appointment to bring in referrals, and worse, some of them are actually hard to refer to.

I will often try to offer some overflow referrals to these peers. It becomes like twenty questions: “Do they plan on using insurance?” “What kind of insurance do they have?” “How did they get your name?” “Did you tell them to call me?” “Did you tell them I’d be calling them?” “What kind of therapist are they looking for?” “Are they looking for Saturdays? I don’t do Saturdays.” The list goes on. These folks are sending very mixed messages: They want referrals but they don’t want to do any of the work for them. They are concerned about the vacancies in their practice but don’t seem to want to make a phone call and ask some questions.

Look, I know that your time is valuable. Mine is too. And when I give you a referral isn’t it worth your time to make the call even if it turns out not to be a fit? The narrower the opening you leave in your referral process, the fewer referrals can get in!

The reason I have so many referrals is because I worked long and hard to develop multiple referral streams. I join EAPs on the other side of the US so I could be their only provider in MA. I advertise in every free online venue I can. I have a presence online in Psychology Today, on Google and HelpPro. And in real life I am constantly talking with my colleagues, networking, sending out newsletters and giving workshops. This all occurred during those hours I had vacant in my practice to start with, and still occurs, sometimes at 2:00 AM! I’ve got my own hell to raise, so when I pass along a referral, don’t expect me to do your footwork for you.

We therapists need to cultivate our aggression when it comes to getting patients. No, I don’t mean going out and clubbing them on the head to drag them to our office. I mean that we need to be willing to spend hours marketing ourselves, refining our strategies; hours and dollars on consultants and coaches if we need to learn how to do this. We undervalue that part of the business, worse, we sometimes act as if we think it is below us.

Let me give you an example. If you are someone who provides private supervision, what do you do when someone walks up to you at a workshop or meeting and says, “so I have this difficult patient and I want your perspective.” And then they launch into the case presentation right there. Would you begin supervision on the spot? Of course not. You’d say something diplomatic like, “I’ll be happy to set up a time to talk and think about this with you.” Because you value the importance and the seriousness of clinical supervision. And you’d most likely never walk up to someone in a similar situation and presume to do the same in reverse. But I can’t tell you how many times people approach me and other practice consultants I know as if growing their practice is a 5 minute conversation topic. How devaluing!

Learning to build and market a private practice is a process, and those who have expertise in it have a skill set just like the other skill sets that go into running a therapy business. None of the successful psychotherapists I know are waiting in their office like film noir gumshoes for their phones to ring. We don’t have time for that. So bring your laptop to work, brush up that LinkedIn profile, ask that senior colleague out for a coffee and network, or plan that public workshop that can give potential patients a look-see at you. If you want your practice to grow be ready and willing to invest your own time, money, and energy into it. Consult experts and do the footwork. And if someone offers you a referral with just a name and a number take it, and assess the referral on your own time.

I know that this sounds like a tirade, and please don’t think I begrudge helping a colleague out. That is one reason I offer you these blogs and concrete suggestions. Just keep in mind that the reason you don’t work in an agency anymore is because you wanted to own your own business, and that means you have to do much much more outside the 45 or 50 minutes with patients. So this week, what are you planning to do outside the therapy hour to grow your practice?