Fear Is Where You Start From

Recently I was having dinner with some colleagues, who were discussing the state of mental health and managed care.  When these conversations start I sometimes begin to sit back, because I anticipate the worst.  I expect that there will be some insurance bashing, and then discussion of how their salaries have shrunk, and how unfair the current system is, maybe a smattering of how better things used to be for our profession and concluding with uncertainty about how much longer they can stay in business.  I expected this conversation to go the same way, and was preparing to decide whether to try to advocate for another, more empowering perspective.

I was pleasantly surprised.

The conversation did indeed start with the understandable concerns of therapists trying to grapple with the seismic shifts in our careers and businesses.  But then one of them began to talk about how he was planning to change the way he did business.  Others expressed curiosity about the things he was trying, and I finally offered a couple of ideas.  When they found out that I provide consultation on building & maintaining your therapy practice, they were 100% enthusiastic and eager to hear some positive perspectives.  They were able to hear my opinions of some tough truths, that we had bought into the managed care model because we were reluctant to market our businesses and have difficult conversations with patients about payment.  No one was defensive at all, one even invited me to come talk with a local group of colleagues.  At one point they made a joke about my “secrets” for success, and I told them I am not one of those people who holds back secrets to hook people into working with me, and that they could find a lot of free info on my site.

“I was kidding about having a secret,” one told me.  “You don’t have a secret, what you have is a strategy.”

The Buddhist teacher Pema Chodron writes in her book of the same title, about going to “The Places That Scare You.” The goal of the Tibetan Buddhist practice of tonglen, or taking and sending, is to reverse the normal cycle of human existence.  Rather than seeking out things we desire and avoiding suffering, the meditation practice of tonglen asks us to imagine inhaling and taking in the suffering for all sentient beings and exhaling happiness to send it to all sentient beings.  Whether you believe in the mystical qualities of this, the principle is a useful one in that it teaches us to break the instinctual habit of trying to holding on to the things we like and get rid of the things we don’t.  A version of this is going to the places that scare you, rather than running away from them.

The clinicians I have mentioned above are well on their way to maintaining and vastly improving their private practices, and its got nothing to do with me.  They have realized that fear is real, and that it often is mistaken for the end of the line.  They get that it is the opposite.

Fear is the place you start from.

People who deny that things are changing are in my opinion in for a rude awakening.  They deny the way our profession is being challenged, the importance of emerging new technologies, and the evolving practice of psychotherapy.  They deny the things that would evoke fear in them.  This is not unique to therapists of course.  Ironically, we often work trying to help patients see the devastating impact on their lives of repressing anxiety-provoking truths.  Then we turn around and do the same things to ourselves, hoping that this change in  economics or technology is “more of the same.”  Folks in this group are in pre-contemplation of fear, they haven’t even gotten that far.

Then there are clinicians who have gotten that things are really changing, and they are terrified!  They are paralyzed and miserable, commiserating with others and talking about the way things were in the past and how much better they were then.  They see the point of fear and they think of it as the period on a life’s sentence of struggling.  This is the end of our careers, we can’t learn to use technology, therapy is a dying art form.  They give up, and go out of business in a lingering dwindling sort of way.

Fear is not the endpoint.  Fear is where you begin. Fear is where you get going and hire a coach, research and write up a business plan, take a workshop on business development, marketing or integrating new technologies.  Fear is the start of renovating your practice.  Yes there is a lot of suffering in the world, let’s get going and reduce it.

Epic Therapists know all about fear. They aren’t fearless, there’s a lot to be worried about.  Many businesses fail, money needs to be spent to make money later, there are long hours ahead and no structure but the one they give themselves.  There is a lot they don’t know, a lot they’ve never learned to do to run a business, known expenses and surprises.  But Epic is running toward that dragon, knowing this could be an epic failure, being afraid… and then doing it anyway.

Epic Therapists have learned the concept of “nevertheless.”  I am scared that my business will fail, nevertheless I am starting it.  I am afraid that I’ll rent an office full-time and not be able to find patients, nevertheless I am going to rent one.  I am afraid I’ll sound inauthentic or greedy if I talk about my business to a colleague, nevertheless I am going to talk about my business.  I am afraid no one will want to pay my fee, nevertheless I am going to set a firm “bottom line” fee for myself.  I am afraid that I won’t be able to keep up with the changes in healthcare or technology, nevertheless I am going to make a strategy.

My last post about having a secret headquarters was fun to make, and it was also serious.  We need to have a time and a place for strategizing.  We can absolutely have fun doing it, but this is serious business.  There really are things to fear in healthcare, building a private practice and starting a business.  We need to think carefully and plan, and then we need to begin.

The Importance of Having a Secret Headquarters

What Is The Power of Social Media For Therapy?

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* : )


@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 gamersThe 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?

You Are Not A Non-Profit.

Please do this for me; even if you never contact me and ask for a consultation or supervision, just do the following.

  1. Print out this page.
  2. Cut out the title to this blog post.
  3. Find a picture of your child, partner, parent or other loved one.
  4. Tape the title to the picture.
  5. Place it on your office desk, where you can see it every day.


This week in MA, we had further seismic tremors in the land of health care.  Two tremors in fact.  First, the news broke that our three biggest insurers Blue Cross, Harvard Pilgrim, and Tufts had reported financial gains this past year and strong investment income.  In addition, the story reported that the CEOs of these companies made salaries ranging from 780K to 1.2 million dollars.  News also revealed that BCBSMA’s board members collected an average of $68,000 last year to attend board meetings.  That’s roughly $1,100 an hour.

The other big insurance news was that Tufts and Harvard Pilgrim decided to call off their merger.  The reasons cited were that there wouldn’t be enough savings to offset the cost.  Translation:  They just wouldn’t make enough money to make it worthwhile.

What does this have to do with anything?  Lots.

First, the salaries and board stipends underscore that Blue Cross Blue Shield is a non-profit business.  That is why if you look at this list of BCBSMA’s Board of Directors, you will see top-ranking business-people and government officials.  Put simply this means that it can dispense its surplus to reward board members and top management.  They are a franchise, and in many cases, publicly-traded companies.

Second, and this is a reiteration of the first in a lot of ways, health-insurance companies are designed to make money, not just break even.  They are a Non-Profit not because they don’t make money, but because of the way they disburse the money made, to their managers and board members (who incidentally are some of the people who have legislative power when it comes to healthcare reform.)

Back to your picture and my post title.

You are not a non-profit.  You don’t even have to play the shell game with board members and management, because you are the management.  It is understandable and easy to get distracted by the rage and yes, envy, that one feels at these “fat cats” making so much money.  But let’s get real honest now.  Here, I’ll go first:

1. I’d love to make 1.2 million dollars a year.

2. I live in a capitalist system, not a caste system, which means that just because I was born in a capitalist system I don’t have to live here, or, I can try to alter the system to be more in keeping with my socialist goals.  But as long as I live in a capitalist system, money is an inevitable fact of my existence.

Now the hardest one, at least for me:

3. The minute I accept insurance reimbursement I become part of the medical establishment, and that means that the sickness and suffering of others is what creates a need for the commodity of psychotherapy.  In other words, I need a steady stream of unwell or hurt people in order to make my living. If I do my job well enough, people won’t need me any more, and I’ll need to attract other hurt or unwell people.  And even if I try to gussy it up in the form of “self-help,” I’ll still need people who need help.

Now I am not going to try to justify this to you, gentle reader, by saying I only make as much money as I need.  I don’t believe greed is good, but I do want an iPad, and I don’t need an iPad.  So I have to come clean and admit that I am not an non-profit.

I consult so often with therapists who take great pride in the amount of “slide” they have in their sliding scale.  They are willing to give up that money without a lot of regret.  Until they take out that picture of their family that I ask them (and now you) to put on the office desk.  Look at it, at them.  Those are the people you love, they are also being affected when you don’t charge full fee to someone who just got a new job, or when you don’t enforce your cancellation policy.  They are the ones who are depending on you to help keep your family afloat.  They are the ones who embody the best care you can give, and they will be with you and counting on you the rest of their lives in one way or another, often financially.

You are not a non-profit.  You need to make a profit, and you need to stop pretending you don’t, and minimizing the profit so that you can pretend.  I hate insurance companies and a lot of our healthcare system, and I am fighting for social justice when I am not working in my practice.  But these companies get it, they get that they are in business.

We need to get that too.

Are You Out There?

"Adolescence" S. Dali

One of my favorite performing artists, Dar Williams, wrote a song with the same title as today’s blog, inspired by her childhood experience of listening to late-night radio.  In it she sings:

Are you out there, can you hear this?

I was out here listening all the time
And though the static walls surround me
You were out there and you found me
I was out here listening all the time

It is an ode to the late-night radio DJ, both a calling out for reassurance and assuring that she is out there listening as well.  Williams recalls the poignant sense of isolation that we forget adolescents experience, often to the point of despair and suicide.  Even working with teens, it is often hard for us to look beyond the behaviors and see the intense feelings many experience.  Because when we do, we remember.

Adolescence is the first time we experience loneliness with self-consciousness.  As children we experienced the immediacy of loss and abandonment, as terrifying as it was all-consuming and eternal.  As adults we will have come to abstract loneliness into a fact of life or a thing to be avoided.  But as adolescents, we take our first steps across a new threshold of mentality, and we become aware of our loneliness.  Perhaps this is one reason why the peer group is so important to youth, at this moment of existential awareness that the planet is really a lifeboat afloat in something so freaking big.

Winnicott often remarked that it is a developmental achievement to have the capacity to be alone, and requires the experience of being alone in the presence of an empathic, quiet other.  I have found this an invaluable thing to remember when sitting with an adolescent sprawled on a chair in my office who was in danger of being labeled “sullen” by me.

It is important to know that someone is out there listening, and I have been reminded of this recently not by my work with adolescents, but by working with therapists.  Every blog post has grown my readership (thank you!) and as it has grown so have the comments on the blog and the emails behind it.  People write to me about their practices, why they decided to take the plunge, what they are worried about, how their supervision has gone, or a victory of self-care.  They write me about how angry they are at the government for changing the rules, how angry they are at insurance companies for lowering their fees, and how angry they are at me for sounding so rigid about online boundaries.

And I hear from gamers as well.  They say how glad they are to read my blogs taking a pro-gaming stance rather than condemning their lives; they tell me how frustrated and confused they are that more therapists don’t seem interested in learning about these things and therefore them; and how angry they get at the media each time it hypes a new study about online addiction or “pathological gaming.”

I have remarked in my contact page that I discourage brain-picking, that act of trying to get free consultation without paying for it in the guise of asking “just a quick question.”  But I could read emails from the above people all day long.  They share so much with me, and those authentic voices, even those who don’t go on to buy my services, are always valued.

Another great thinker, Alanis Morrisette, says, “There is no difference in what we’re doing in here/That doesn’t show up as bigger symptoms out there.”  Our world is broken, and there are many people alone together in the lifeboat, people who have forgotten the wisdom of holding onto each other as adolescents do.  You know this, you work with these people, I work with these people, and we are these people.  We all need to regress a little, to remember that secure solitude begins in the presence of another who cares.

So if you have been thinking about commenting or writing, please don’t hesitate.  You deserve to have someone you can be alone in the presence of, and I am out here listening.  I really am, and if you’re anything like the epic therapists, gamers or patients who have already written me, I know you’re a rock star too.

Epic Therapists

The Jabberwock by Tenniel

I’ve been on a pretty steady soapbox about video games, and play this past week, and that was not a coincidence.  The post I did about HIPAA attracted a lot of positive attention, and some negative. I think the title had something to do with it, in that it was a tongue-in-cheek title.  There’s no such thing as a 100% HIPAA compliant practice, and I was poking fun at the fear-based mentality that sometimes consumes us when it comes to our practices and being sued.  When my readers poked back, I realized that I needed to explain my perspective, so this post will hopefully clear things up in terms of using technology in therapy and preparing your practice for health care reform.  So let me try to do that now:

We live in an era of fear.

That’s it in a nutshell.  There is so much change and synergy going on today that it can be overwhelming.  Technology, in particular social media, is evolving faster than many of us know how to use it. So we turn away from it in fear and disinterest.  The HIPAA issue is in many ways the symptom of that, but it is also a red herring.  The way we live and work is changing, and we don’t want to change.  We want therapy to begin with the first phone call or the greeting in the waiting room, occur only in the office between two people talking, and end at the 45-50 minute mark.  And for many of our patients, that works, and for much of the time, that works.  But things are starting to slip, expand.  Our potential patients want to know something of us before they even call, so they’re looking for our website.  Patients from all over the world are seeking out therapists with particular expertise via Skype rather than the brick and mortar office.  And between sessions our patients are following us on Twitter, asking to friend us on Facebook, or reading our blogs.  The ability for us to remain as mysterious as we used to be is being challenged.  We are googled, and this raises our own ethical concerns about whether we should google our patients.  So technology scares us, and we feel it threatens our profession rather than opens new avenues to us to practice our craft.

We are also scared of health care reform, ACOs and global payments.  We have grown reliant on the way we have come to do business with health insurances.  In the 1980s in Masachusetts, insurers like BCBS offered their subscribers $500 worth of coverage, that was it.  There was no parity, and many of our patients paid our full fee out of pocket.  Somehow they found the money, sometimes they went without treatment.  In the intervening decades many of us made a “deal with the devil,” agreeing to play by insurance companies’ rules in return for the steady fee-for-service reimbursements we got.  Sure we sometimes complained about how long it took to get reimbursed, or the clinical reviews we had to do, or the paperwork.  But we signed up for the insurances for a reason, we wanted security and steady referrals.  And we raised a whole generation of therapists who saw insurance reimbursement as a necessity, not an option.

Worse still, we stopped needing to think with our colleagues and our patients about whether we were doing valuable work. Our patients grew to take it for granted that therapy cost $15, and we grew to think we might only be worth that much.  So when insurance companies put incremental demands on us, we acquiesced.  When they lowered reimbursement rates, we acquiesced.  And we did this, we do this, because we are afraid. And because we are afraid, we keep doing business as usual and rely on the insulation of a third party reimburser to protect us from having the conversations we need to have with our patients on what and why they need to pay for their treatment.  We bought into this system because we wanted to avoid those conversations.

Health care reform, if it survives, will be an amazing boon for Americans.  Mental health parity has already in MA helped thousands of people get and stay in treatment.  As our politicians hammer out the details, our professional organizations are being called on to weigh in on how to move to the new structure of treatment and reimbursement.  And to their credit, they are doing what organizations like that need to do, ensuring that they have a place at the table, and speaking out loudly and strongly to advocate for patient care.  And yes, they also represent us, but we need to understand that we don’t come first in many ways.  The people who need to fight for our businesses are us.

I need to advocate for my own business, make my own business plan, set my own fees, adhere to my own fees, set aside PB+5 or low-cost sessions to have a socially just AND profitable practice.  I need to be able to have the difficult conversations, to tell people why I am worth more, why the work we are doing is worth more, than $15. That is my job as a business-owner, even if the business I am in is healing the mind and soul. I need to wean myself off an insurance-only practice, diversify my revenue streams.

In short, I need to become an Epic Therapist.

Epic therapists, don’t play it safe all the time.  They know that to get the epic loot they need to try and fail and try and fail again.  Epic therapists know they need to network with a group of strong co-players, and learn new strategies to try when the old ones won’t let them down the boss.  Epic therapists “learn the fights,” they spend hours learning about how to be the best they can be and let other people know what they are good at.

Epic therapists aren’t good at working with every single patient problem or person in the world.  Those type of therapists, who maintain that they can do equally excellent treatment with anyone for any problem are what I call “Non-Player Character Therapists.”  In video games, a NPC is a character in the game like a robot, that anyone can click on and they’ll get the same conversation and quest.  NPC therapists have no sense of agency.

This was all a long prelude to what I really wanted to do today, which was to introduce you to some Epic Therapists.  These are people doing amazing work in their own unique ways. So here are three epic therapists:

Debra Totten

Deb is a social worker in CA with over 25 years of experience working with adolescents and their families.  Deb specializes in adolescents whose anger and distress have often landed them in a lot of trouble with the law, schools or their families.  Deb is not afraid to fight for the kids she works with, and will often go head-to-head when she is required to testify on their behalf.  When I’ve spent time with Deb I’ve been impressed with her energy and authentic cheerfulness.  If you are looking for a therapist who “gets” teens and “gets” the technology that is so much a part of their lives, click on the link above and contact Deb.

Brenda Corderman

Also in CA, Brenda is an LMFT who specializes in working with couples.  She also specializes in advocating for the voice that may have a hard time speaking up.  Brenda may not be the loudest person in the room, but she’s definitely one of the most attentive and thoughtful.  In addition to her experience with couples, Brenda has a particular interest in working with couples where one or both partners has been identified as gifted.  If you are looking for a therapist but are shy about therapists and therapy in general, Brenda is a good bet.  Brenda is also beginning to branch out into online therapy, so you may want to inquire about that as well.

Carolyn Stack [Affiliate]

A seasoned clinician with an extensive background in psychodynamic theory and trauma, Carolyn has also been practicing for over 25 years.  She has a specialty in evaulations for persons with complex trauma seeking immigrant status, and has testified numerous times as an expert witness.  She frequently teaches and lectures on the impact of trauma from a psychodynamic perspective, and in her private practice she has a specialty of working with emergent adults (18-25) who are struggling to maintain their schooling or jobs after having had a psychotic episode or severe depression.  Carolyn is not afraid to go to the deep places with her patients, and stay with them through the terror that can exist there.

These are just a few examples of the Epic Therapists I know.  Who are some of the Epic Therapists you know?  And what makes you an Epic Therapist?

How to Have a 100% HIPAA Compliant Online Presence

Fort Knox photo courtesy of Flickr

Many of you have asked me about protecting the privacy of patients in your practice online. Since this concern with privacy often feeds into the anxiety psychotherapists have about using social media, I wanted to offer you a way to build your online presence with an eye to best practices and a sense of confidence. So here is my instruction manual for having a practice that is 100% HIPAA compliant and respectful of patient confidentiality and therapist privacy. Do these things and you will never be in trouble.

1. Don’t talk about your patients online, ever.

People who work with me know that I am nonnegotiable on this one. Yes, in the 15 years I’ve been a therapist I’ve had plenty of poignant and instructive cases I could present and patients I could discuss. No, I am not going to tell you about them. Not on the internet anyway. The internet is not like a team meeting or case presentation, where you have a closed group of professionals discussing patients and asking for consultation. Anyone can read the posts, and patients can easily identify themselves (or imagine that they do) in your blog post. And if Facebook resets your privacy settings one day and I’m your 2:30 patient; and if I Google your Facebook as patients do at 3:25 and find you’ve just updated your status to say, “Just finished with the tough patient for the day, it’s all downhill from here;” then I will know, be offended, and if I’m savvy and litigious get ready to make some money to pay for the new therapist I’m about to hire.

And a special shout out to those of you who use forums such as LinkedIn and Psychology Today, even if you think your forum is open “only to professionals,” does it not occur to you that your patients are or one day could be in your profession? I look at some of the many forums I am on sometimes and I am horrified by the headings, which often resemble these:

“Wow, this patient is so self-centered!”

“What’s the funniest that thing your patient said in session today?”

“Potential clients wants to see me instead of my colleague they see now.” (Let’s hope the colleague doesn’t read the forums.)

and “I don’t want this borderline back! Help!” (Complete with a page long “brief” case presentation!)

Several of these have so much identifying information it’s not funny. And as for LinkedIn, most discussion groups are now open and searchable by web, so when you write in asking for advice about an adolescent smoking pot don’t be surprised if she ends up seeing it.

In closing on this one: I know we all need to vent and ask for help with patients from time to time. That’s what supervision is for, go buy some.

2. Life is temporary, the internet is forever.

Before you post anything, ask yourself how you would feel if it was printed on the front page of The New York Times or some similar print edition. Everything you post on the internet is housed on a server somewhere; backed up usually; then often trawled for and picked up by Google and made searchable. Once you put something on the web it stays there, even if you think you deleted it. So ask yourself, “Is it a good idea to have what I’m about to write floating around wherever it will forever?”

3. Don’t create an online identity that you aren’t prepared to have connected to you.

The nature of privacy is changing due to technology, and that means we can’t be assured that any identities we assume online will remain private now or in the future. Servers get hacked, laptops get stolen, and people, patients included, are very resourceful in satisfying their curiosity about us. So if you have specific groups or personas that you want to let loose on the world via WoW, alt.com or anywhere else, be prepared. If I can’t imagine myself being able to hold a conversation with a patient about their discovering a potential “secret identity,” I don’t create it. I know this may sound harsh, but this is one of the privileges we give up for the privilege of doing the work we do.

4. Don’t subscribe (or unsubscribe) to things you don’t want patients or colleagues to know about.

Subscribing to things is a choice, and you need to be prepared to have those choices made public. This ranges from sites which tell you how much a person donated to the Democratic Party to a blog or listserv. And in terms of collegial relationships, do not risk appearing deceitful by opting out of a Constant Contact list and then telling the colleague how much you enjoy their newsletters. Yes, this has been done to me, and I try very hard to resist telling the person that I can tell them the exact date day and time they unsubscribed on my CC account. Subscriptions and unsubscriptions are expressions of your agency online, express your agency with integrity.

5. Understand how email works.

Recently I agreed to provide coverage for a colleague, and when they offered to email a list of who I’d be covering I requested that they mail it. This surprised them, because they know what a technophile I am. When I explained it is because email is not secure they replied that the mail isn’t secure either, and that envelopes often arrive opened. That is an unfair comparison between email and mail in my opinion.

A more accurate comparison would be if you write a letter, make a copy for yourself and send me a copy; and then someone opens the letter at your post office, makes and keeps a photocopy of it and mails it to my post office, where a second worker opens it and makes and keeps a third copy of it before giving a fourth copy to me. That is how servers work, that is how hosted emails work. If you don’t want four or more entities having copies of your emails, don’t send them. If you want to send encrypted emails, which are definitely more in keeping with HIPAA and HITECH, I recommend Hushmail.

6.Keep current with the technology if you plan on using it.

You know I encourage you to try and use technology as much as possible, so the above may sound like an impossible and counterintuitive task, but there you are. If you are planning on taking pictures of your children with your iPhone and posting them on Facebook, make sure you know about geo-tags before you go about using Facebook or Craigslist. If you are considering using Dropbox or GoogleDocs for patient notes investigate whether these are verified as HIPAA compliant (I’ll save you time on this one: They are not. Don’t use them for patient notes.)

If you want to play around with some new technology, research it a little (Google “[whatever you’re playing around with] and privacy.” If you want to keep current with technology and best therapy practices, I recommend you check out the Online Therapy Institute’s “Ethical Framework for the Use of Technology in Mental Health.” They are on the cutting edge of this stuff, and they have great courses as well as free resources.

So these are my suggestions for having an online presence that is HIPAA compliant and protective of your patients’ and your privacy. I know they are a tall order, but the privacy of you and your patients is worth the effort. Please feel free to add: Did I miss anything?

Tweaking 2011

photo courtesy of profalbrecht.wordpress.com

This is my first blog entry on Evernote.  I’m excited about that because learning and trying out Evernote is one of my 2011 goals.  More about that in a sec.

One of the reasons I love supervising therapists is that it keeps me honest and focussed on innovation.  The other night I was talking with a supervisee about scheduling our time for the upcoming year.  Would an evening time on another day work better for me? (Quite a thoughtful supervisee, not an uncommon experience given our field.)  I found myself answering that I wasn’t sure yet, because I needed to re-evaluate my evening time.  I have been noticing a drop-off in my work with adolescents, and have been coming to the conclusion that if I want to keep working with adolescents I’ll need to give up some of my evening time.

This time of year is an excellent time of year to give your practice and your career the lookover.  In the past several years I have gravitated to more traditional hours so I could pursue other projects.  For example, my professional development and networking goals for the past year and a half have been fulfilled by my Fellowship appointment at the Massachusetts Institute for Psychoanalysis.  In 2009 I identified the need for more collegial contacts and friendships as well as wanting to have CEs for my license.  The Fellowship has provided me both in abundance.  Like many of my actions to meet my goal, the MIP Fellowship was a “twofer.”

I always try to have as many twofers or threefers as possible, so that I don’t overwhelm myself with actions to meet the multiple goals.  Twofers are important to me because I want to consolidate my actions, but not my goals.  So I list my current goals and then put the actions under the goal(s) it fulfills.  I also rate it hot or backburner.  That way if I have a few actions I make myself evaluate the relative strength of my interest to do each.  So follow me along for an example:

Professional Development Goal

  • MIP Fellowship- heading towards backburner.  This is my last year of it, and I’m ready to move on to a different structure and get my Monday night back.
  • Program Exploration – hot.  I need to begin planning on what I will do to replace the Fellowship, which means taking a look at workshop or mini-course offerings or webinars that happen during the day.  Am I willing to give up my weekends yet?  Traditionally I have balked at Saturday workshops, so I am revisiting this.
  • Continuing Ed on cultural competency working with transgender population- hot.  My practice has been trending towards an increase working with this population, so I need to invest time in updating my skills in theory and best practices.

Clinical Therapy Goal

  • Adolescents- hot.  I have noticed that I am trending downward in my work with adolescents, a population I love.  Most adolescents require parental transportation and can’t miss school regularly, so I need to revisit my giving an evening up.  Saturdays? No.  (This is an excellent example by the way, of how there is no one right answer for this.  My colleague Susan Giurleo regularly works an evening and Saturday, and there are lots of good reasons for doing this.  I have consciously chosen the last 2 years to not have an evening because the evening time was more valuable to me than the money I was choosing not to make.  Choosing not to make money is different than saying, “why can’t I fill my practice, whoa is me.”  Money is one item of value, time is another, it is up to you to choose what you want to give up.
  • Gamers- hot.  I want to continue to focus on working with more gamers.  I need to revisit where and how to get referrals.  This year I will try to offer more public speaking opportunities to colleagues to increase awareness of gamer-affirmative therapy.  Also will use Twitter to remind my followers of my interest in working with this population.
  • Couples work- backburner.  Even on my best day, this is not my preferred modality.  I will maintain my “no more than 3” couple limit, but am tweaking it to focus on private pay, gamer couples or online therapy.

Technology Goal

  • Twitter-hot.  I continue to find Twitter useful, but am tweaking it a lot.  I will use it to Tweet blog articles or RTs and hold to my goal of 2RTs and 2 salient tweets (i.e., tweeting something I think is relevant professionally rather than for the sake of Tweeting.  Recently I have fallen short of this goal because of the magnitude of tweets that come my way.  Will add this to my Epic Win program and scale back on how much time I spend reviewing.  Will keep an eye out for Tweet-management software to see if I find any I like more than TwInbox.
  • Evernote- hot.  I have heard about how great Evernote is for too long from too many people I respect to ignore it.  I will familiarize myself with this program and try using it for blogging, as well as exploring which other goals it might further.
  • Game exploration-hot. I have been focussing on WoW and Second Life.
  • Rockmelt-backburner.  Still in beta and having some bugs.  Still limiting access so limited as social media.  Shut down and I lost a whole blog post!  I am continuing to play with it a little but relying on Firefox until it gets a little more stable.

Social Justice Goal

  • Give an Hour-hot.  I still find this a meaningful way of donating clinical time to fulfill the gap for returning vets.  There is an increasing number of vets and active duty gaming, and this is a potential twofer with the Clinical goal.
  • Diversity Class- hot.  I continue to find teaching this worth the “pay cut” I take by giving up those clinical hours.  This is a twofer a teaching goal and writing goal on rethinking how we teach Diversity.
  • Masshealth-backburner.  I am opting out of taking Masshealth due to the high cancel rate I’ve experienced in the past.  This is a twofer with my business Goal below of decreasing my involvement with insurance and diversifying revenue.

Business Goal

  • Reduce dependence on insurance-hot.  The writing is on the wall for decreased revenue and increased hassle as Health Care Reform takes effect.  Leave Masshealth and UBH networks.
  • Increase online therapy-hot.  I need to focus on increasing marketing for this modality, it is all private pay and more flexible in time to meet patients and my needs.
  • Increase consultation and supervision-hot.  Supervision and consultation was the biggest growing area of my practice last year.  Need to poll current consultees about what they find most valuable so I can emphasize that.  Be willing to slide down to my bottom line to attract supervisees in early stage of their career.  Make and post more video on supervision and consultancy.
  • Advertising-backburner.  Google Ads not yielding much ROI, decrease ad bids.  Stay on Psychology Today for next year but focus marketing/advertising through speaking engagements.

Teaching Goal

  • Additional psychodynamic class-hot.  New syllabus written and course approved.  Hopefully this will be offered this summer, will apply to teach it.
  • One class per semester-hot.  This tweak from two classes one semester and one the next was a big improvement.  Evaluations better, enjoyed work more.  Will consider whether to make up third class by committing to summer course regularly.
  • Offer visiting lecture or workshops to universities-hot.  This year I want to get out to more college health centers and schools for social work to present on gaming.  Tufts very successful, will look for opportunities to present at other universities.   Put the word out, twofer with business and professional development goals.

Writing and Research Goal

  • Newsletter-hot.  The readership response has been positive and begun to generate revenue.  Need to stay focussed on keeping newsletter relevant and yet distinct to my niche.  Review of clicks indicates that the psychoanalytic topics are more popular than the gaming ones.  How can I increase traffic to those stories?
  • Blog-hot.  Now have over 100 readers subscribed, and growing.  Need to continue to make this a focus.  2-3 posts weekly remains doable and will maintain 2 minimum.  Again, the practice/business posts are more popular than the gaming ones, need to consider how to increase interest in those articles.  This is a threefer with business and clinical goals.
  • Journal article-backburner.  The style and tone of blogging is much more satisfying currently, will revisit later in the year to see if this changes.

So that’s my beginning of 2011 review and tweak.  It took me 40 minutes to think and write about this.  Don’t you think it would be worth 40 minutes of your time to do the same?  What are your goals for this year, feel free to use the blog comment to get started!

How Invested Are You?

photo courtesy of Flickr

When you decided to become a therapist, how much time and money did you spend?  Most therapists spend between three and six years (longer if they are MDs) enrolled in graduate programs that cost thousands of dollars.  That’s a lot of money!  But we do this because we value the profession, the work we do, and the people we help.  We also do it because it’s reality.  You don’t show up, knock on the door of a graduate program, and say, “hey, can I sit in on a few classes for free?”  You want the education and you pay for it, by loan, scholarship or somehow.

It astounds me how this logic seems to go out the window when it comes to growing a therapy practice in a Web 2.0 world.  This is probably because technology has become so easy to acquire.  You want a blog?  WordPress will let you get registered and started in 15 minutes.  Twitter, takes 10 minutes and a valid email to enroll.  So I see a lot of colleagues decide to “take the plunge,” start a blog, and then..


Nothing happens, or they don’t get traffic.  Or they run out of ideas.  Maybe they ask me for some advice, offer to buy me a coffee if I can help them with their blog.  “Can we just chat?” they’ll say.

Then there are people like my colleague Carolyn, who hire me.  That’s right, hire. She wanted some help with her blog, both in terms of the technology and setting it up, as well as market consultation on audience, focus, and sustainability.  So she spent the time and money to do this, and even though we’ve just started working together she’s already seeing more of a focus in what she’s doing.  We’re backing up and unraveling a few stitches, so that we can get her and her practice ready for the 2011 business year.  Carolyn is going to thrive, and not because she hired me:  She’s going to thrive because she is investing in her practice and taking technology seriously.

Taking technology seriously means at least two things:

1. Taking technology seriously means you accept that the point in history when using technology was optional is over.  You can no longer ignore or opt out of using technology to have a successful practice.  Whether you use email, social media, file claims electronically, request authorizations, etc., if you do not start utilizing the resources that technology affords you you will fail.  I know that sounds brutal, but your colleagues will pass you buy.  Web sites will trump the yellow pages every time.

2. Taking technology seriously means investing time and money in learning about it and how to use it. Just enrolling in a blog service is the equivalent to signing up for a psychology course, and then going out and hanging up your shingle.  You’d be insulted if somebody implied that they could duplicate your expertise and services after taking one class or workshop.

Yet, I can’t tell you how many people approach the Web 2.0 practice that way.  They’ll email me a question or two, ask for a free consult (which I no longer do) and I think on some level they are expecting that what they will get will be commiseration or something.  A friendly “chat.” They really don’t take technology seriously, so they decide they’ll just do it themselves.

Where does he get off saying this?!

Let me give you a breakdown of the work I have done and the expertise that I have:

  • I have been a psychotherapist for over 15 years.
  • I co-founded a social media software company; meaning I participated in a startup business in many capacities to grow it.  I pitched ideas to clients at meetings, helped orchestrate launches, analyzed client needs, kept an eye on marketing trends; wrote press releases, managed budgets and negotiated CEO contracts.  Oh, and I also helped develop the product that several versions and six years later is one of the social media companies to be included in the latest Gartner Group report.
  • I have spent countless hours researching the changes and developments in the social media industry, and compared to my company’s employees I am behind the curve.  This is because I am not involved in the company’s day to day ops, and because I am focusing on doing the other projects you read about.  But I know social media, from a user experience and business perspective, and it isn’t from downloading Twitter and playing around with it or making an Excel spreadsheet.
  • I invested in my own supervision and consulting from top clinicians and coaches.
  • I have started up and grown a private practice from zero patients to a full practice in 30 weeks.  I can tell you it was 30 weeks because that is the amount of unemployment benefits I received to survive on while I built it.

So I know what it is like to take the plunge and how to make it work.

I am saying this to you because you need to take technology and growing your business seriously.  Sure if some people read this and want to consult with me, I’ll be very happy.  But if not me, please, hire somebody.  Susan Giurleo does great work, so do Casey Truffo and Juliet Austin.  And Lynn Grodzki is amazing.  Heck, check out a couple of people; we all have different styles, experience and foci.  But accept that taking your business seriously means asking for help and hiring experts.

So, yes, of course I am marketing for your business, but I am also trying to convey something more:  If you do not invest in the time and expertise to build your practice in the 21st century you will fail.

P.S. If you want to get help on generating blog ideas, a great source is Chris Brogan’s service, and yes, you’ll have to pay for it.

The Readiness Is All

Engraving by R. Brandard


There ’s a special providence in the fall of a sparrow. If it be now, ’t is not to come; if it be not to come, it will be now; if it be not now, yet it will come: the readiness is all.

Shakespeare, Hamlet. Act v. Sc. 2.

This time of year is for many of us quiet and busy and full of expectations.  Many of us our preparing to celebrate a holiday, and all that entails.  Some are getting ready to do last minute shopping; some are getting ready to cook and buying the necessary ingredients.  Some therapists are getting ready to take a vacation; some patients are getting ready to face the holidays alone or with family they find challenging.  And after the Christmas day, and Boxing Day if you want to push it, much of the world slides into a week or so of winding down until the New Year hits.

I enjoy Christmas, but I have always found Advent much more interesting.  Advent as you may know if the Western Christian season that marks both the coming of Christ and the end of the liturgical year.  It is the season of quiet expectancy.  There is silence, there is waiting.  A candle is lit each week until Christmas, and there are these great advent calendars, with doors for each day that you open one at a time to reveal the picture or treat underneath.  And for the techies and gamers amongst us, the best example of this sort of advent calendar is the one from Angry Birds.

This is NOT going to be a post about the Christian Advent or religion, but it IS a post about business, and the spiritual concepts that can (and I think should) be applied to your business.

I am looking forward to celebrating the holiday season, and yes I plan to rest and reflect.  But unlike Congress I am not sliding into a lame duck session.  I am using these last two weeks to get ready.  I’m getting ready to teach a course on psychodynamic theory, getting ready to right a series of blogs on ludology and tweaking the business plan for 2011.  My friend and colleague Susan Giurleo is getting ready to do her latest teleseminar with Juliet Austin on Social Media Marketing.  My friend and colleague Carolyn Stack is getting ready to ramp up her new website with a blog.  My clients are busy doing their interim homework for me on building their therapy practices, and MIP is rolling out a whole bunch of workshops.

Ok, so what are you getting ready for?

You knew it was coming if you’ve ready any of my blogs before.  Mike gives examples and then pounces, asks me what I’m going to do.  Yep, what are you getting ready for?  Do you have a workshop in the works?  A satellite office day?  Twitter script for a CBT adolescent group? Are you teaching a course at a local university, or doing a public forum for colleagues on something you are expert in?  Writing a chapter, article or blog?  Joining a political activist group?  Adding a new skill or modality to your repertoire?  Learning about Skype?  Getting on Twitter to check it out? Or if you want to be a gamer-affirmative therapist, picking a free trial of a game, downloading it and playing around in-world?

Now some of you naysayers in the back are probably saying: forget it.  This has been a hard year, health care reform has sucked, my patients have tired me out.  My work is demanding, I deserve a break.  I’m going to rest up and plan this stuff next year.  Of course you deserve a break, I hope you scheduled yourself some vacation time.  But let’s not kid ourselves here.  The next two weeks has lots of room in it for both work and play.  I’ve been winding down work the past week and managed to grade my papers, read a book, and still level a character in WoW to 85 (and yes I am proud of it!)

Please please please don’t end the year on a down note!  Because I guarantee you you will start the new one off with a defeatist attitude.  The boundary between 12/31 and 1/1 is in many ways an arbitrary social construct.  Now is when you should be getting ready for new projects, when you have some flexibility in your schedule.  Because then you’ll be out of the gate running when the first work week of January starts, when many of our colleagues are just sitting down to their desks to brainstorm.  I want us all to be ahead of the pack.

And a note to those of our colleagues, who probably don’t read this, who have already decided they “know themselves” and that they are going to stick with what they have been doing, you’re setting yourself up.  Health Care is changing the way you will be getting paid. If you don’t know what an ACO means and how global payment model could put your private practice out of business, get your head out of the sand and start surfing for info.  Please don’t be like my colleagues who chatted with outrage about the health care changes in MA as if they were political discussions all summer and fall, or even worse ignored the issue, and then FREAKED OUT when they opened the first payment from BCBS that had slashed their fees drastically.

Strong words I know, but I want us all to have strong businesses.  Change is coming, advent is here.

Get ready.