managed care

The Lava Expert

January 2, 2015 by langloimsw 2 Comments

“Sometimes it is the people no one imagines anything of who do the things that no one can imagine.” –The Imitation Game

Shortly before I fell into the lava I began a conversation with an eleven year old girl, we’ll call her Sal. This was a while back, on a Minecraft server I play on from time to time. My name when I play Minecraft has the word “therapist” in it, and Sal had noticed this.

“Hey, are you really a therapist?” Sal asked via our server text chat.

“Yes I am.” I typed back. I had been mining obsidian and using a river to cool the lava so I could chip away at it with my diamond pickaxe. In the time it took to type my reply, I managed to fall into the river and get washed into the lava. I watched myself go up in flames, and with me most of my loot. There is always a chance though, when one falls into lava this way, that some of one’s loot can be thrown clear. So upon respawning I quickly made my way back to the scene of my demise as we continued our conversation.

“Oops, burned up,” Sal said, as the server had announced just that when I fell in the lava. “Are you the kind of therapist that talks to kids about their problems?”

“Kids and adults both, yes.”

“My mother wants me to see a therapist,” Sal said.

“Why?” asked another one of the kids on the server.

“She says I have problems with friends,” Sal said. By this point I had returned to the lava pool. There was no loot that had survived.

“Sal,” I said. “Everyone needs help with their problems from time to time. That’s why there are 7 billion people on the planet, to help each other out.”

For some reason that made quite an impact with the other players. “Wow, you must be an expert!!” one typed. I’m not sure how he’d come to that conclusion.

“I’m certainly not an expert on lava,” I replied, and fortunately the conversation went back to the business of mining after some sympathetic emoticons.

I have no problem talking with kids about therapy, or being a psychotherapist. If I did, I certainly wouldn’t have the word in my userid. And it wasn’t even that I was “off duty.” I’ve had many conversations in chats over the years and heard a range of problems. In part I was a little protective of Sal’s right to privacy, although experience has again shown me that kids are often less hung up on therapy than adults, and in many ways are often more trusting of psychotherapy than adults are. Mostly the reason I wanted us all to get back to playing was that I had caught myself sounding “educational.”

* * * * *

In play if there is any such thing as an expert it is certainly not the therapist, or adults in general. Virginia Axline, knew this. In her book Play Therapy she writes, “Non-directive therapy is based upon the assumption that the individual has within himself… the ability to solve his own problems satisfactorily.” (Axline, 1947) My trainees are often as surprised to find that I am friend to both psychodynamic and solution-focused theories as I am to find that they have been taught the two have irreconcilable differences.

As I see it, my job is often to be a unique experience in the lives of patients. “It is a unique experience,” Axline writes, “for a child to find adult suggestions, mandates, rebukes, restraints, criticisms, disapprovals, support, intrusions gone.” (Axline, 1947) And by the time people come to us as adolescents or adults, those suggestions, mandates, rebukes, restraints, criticisms, disapprovals, etc. have become internalized. By adulthood, many of us feel as if we lack expertise in anything, except perhaps screwing our lives up.

Education has increasingly played a hand in this. We do not teach so that our students learn to think independently and feel resourcefully. Instead we teach them to think like someone else. Critical thinking and exploration become supplanted by the sense that education has to give us something tangible in a materialistic sense: A good grade; a profitable job; published ideas or maybe if we really drink the Koolaid admiration from other academics.

One thing that is so enjoyable about Minecraft for many is its’ open sandbox environment. There is an endgame you can play if you want, but there are also myriad variations of play you can do instead. Sal and millions of other children and adults can range freely through such open and creative spaces without “experts.” Education certainly can happen there, but often in a lightly curated if not autodidactive way. People have created versions of Westeros, Middle-Earth, Panem or their own creations. There are PvP versions where conflict and combat, stealth and griefing hold sway; fantasy realms where people can role-play. It is a topsy-turvy world where children can have the most wisdom, and we adult experts can trip and fall into lava.

* * * * *

In a world obsessed with measuring outcomes, psychotherapy can have a rough time of it. If Sal ever goes to therapy, she will have to be labeled as ill somehow if her mother wants insurance to help pay for it. Notes will have to be written, treatment plans planned, goals and objectives filed away so bean-counters can determine that Sal should get 14 beans-worth of help. It’s hard for me to get too angry at the bean-counters though, over the past 25 years I’ve met a few of them and they don’t seem too happy either.

Education fares little better, with things like the Common Core which tells us what should be taught; standardized testing which masquerades as achievement; and trigger warnings which are supposed to warn students of upsetting content as if they somehow were entitled to get through the mind-altering experience of learning without ever being upset.

It takes bravery to stand up to this. To let the individual chart their own course, make their own mistakes, draw on their own core. For the therapist and educator it takes bravery to get out of the way, to radically reflect the developing self. I do believe that each one of us needs help throughout our lives; but that help needs to be asked for lest we run the risk of telling others what to do and implying they aren’t up to the task of living their own lives.

* * * * *

Many therapists, social workers, and teachers I have met chose to become members of those professions at least in part as an expression of admiration for their own therapists, social workers and teachers. They had no interest in falling into the lava ever again, so they started focusing on helping other people out. It’s a thankless job if you are going to go through it secretly hoping to be thanked. I’m not sure I’ve ever had someone I work with refer to me as an “expert” unless they were being facetious about some blunder I’d just made. And I’ve made many. As an apotheosis, being a psychotherapist or academic is rather anticlimactic, not because the work is devoid of meaning or value, but rather because if we truly place such people on a divine pedestal it needs a steady stream of troubled people to hold it steady.

Perhaps an alternative for therapists, social workers, educators and our ilk is to think of ourselves as “lava experts.” We have some acquaintance with falling into pits, being consumed by intense feelings, losing all our, erm, loot. These are human experiences. This is not a secret to anyone, and I doubt most people would put their trust in someone who knows nothing of failure, obsession, overwhelm or grief.

What’s more is we’ve fallen into lava, often the same pit again and again! We know something of the repetition compulsion. We have let our yearning for whatever we think we need lead us to risky or self-defeating behaviors. We can talk to people about their problems, because we are people who have problems ourselves. We’ve been burned. Minecraft miners know mining deep is risky: We know what we’re doing even up to that moment our bones ignite.

Rather than being an expert on a pedestal, accept that you will tumble into fire, again and again, looking outside of yourself for what is precious. Straight A’s, that book you published, six or seven figures–There’s a little Gollum in all of us. It’s what makes us forget mindfulness, build empires, win arguments or wars. No one was ever oppressed by play, only the lack of imagination that comes from the absence of it.

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Filed Under: Gamer Therapy Tagged With: activism, addiction, adolescents, behavior change, buddhism, children, digital literacy, education, game theory, gamers, games, gaming, HMOs, managed care, mindfulness, minecraft, play, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, social justice, social media, technology, therapy, video games, virginia axline, Web 2.0

Guild Wars: The Conservative Attack on Online Therapy

August 4, 2013 by langloimsw 11 Comments

“European commerce during the Dark Ages was limited and stifled by the existence of a multitude of small kingdoms that were independently regulated and who suppressed the movement of goods across their borders through a confusing and inconsistent morass of taxation, tariff, and regulation. This forced merchants to find another solution to move their goods, one that would avoid the strangulation that resulted from this cumbersome regulatory model. These merchants chose to move their goods by sea without being subject to the problems that were created by this feudal and archaic design, a move that changed the world. The little kingdoms took hundreds of years to catch up.”

–Harris, E., & Younggren, J. N. Risk management in the digital world.

Keeping up with policy is not my favorite thing: But if I am to continue to be a consultant to therapists building their business and an educator on integrating technology into social work practice, it is part of the prep work. So when a recent client asked me a question about licensure and online therapy in our Commonwealth of Massachusetts I surfed on over to our Division of Professional Licensure to take a look. Good thing I did, and a lesson for all of you thought leaders and innovators out there, regardless of what state you live in.

There wasn’t much about technology, except for the interesting fact that the past several Board Meeting minutes made mention of a Committee discussion open to the public on “E-practice policy.” I assumed (correctly it turns out) that this meant that the Social Work Board was formulating a policy, so I reached out to the Division and asked some general questions about what it was going to look like. The answer was prompt and pretty scary.

The representative stated in her email to me that the “Board feels as if the use of electronic means should be employed as a last resort out of absolute necessity and it is not encouraged. The social worker would have the burden of proof that electronic means were employed as a last resort out of absolute necessity.”

I have several concerns about this.

Before elaborating on them, I want to explain that my concerns are informed by my experience as a clinical social worker who has used online therapy successfully for several years, as well as an educator nationwide on the thoughtful use of technology and social work practice. I have had the opportunity to present on this topic at a number of institutions including Harvard Medical School and have created the first graduate course on this topic for social workers at Boston College. In short, this issue is probably the most defining interest and area of study in my career as a social work clinician, educator and public speaker.

I also am a believer in regulation, which is why I have been licensed by the Board of Licensure in Oregon, and am in process of similar applications in several states, including CA, and NY, so that I may practice legitimately in those jurisdictions. I am a very concerned stakeholder in telemedicine and here are only a few of my concerns about a policy of “extenuating-circumstances-only-and-be-ready-to-prove-it:”

E-Therapy is an evidence-based practice. It has been found to be extremely efficacious in a number of peer-reviewed studies, over 100 of which can be found at http://construct.haifa.ac.il/~azy/refthrp.htm . In fact, telemedicine has been found to have comparable efficacy to in-office treatment of eating disorders (Mitchell et al, 2008,) childhood depression (Nelson et al, 2006,) and psychosocial case management of diabetes (Trief et al, 2007) among others. To limit an efficacious modality of treatment by saying it needs to be used only in an “extenuating” circumstance or as a last resort which is discouraged would be a breathtaking reach and troublesome precedent on the part of the Board, which has not been done with any other treatment modality to the best of my knowledge. Telemedicine was also endorsed by the World Health Organization 3 years ago. And as I wrote this post, the University of Zurich released research showing online therapy is as good as traditional face-to-face therapy, and possibly better in some cases (Birgit, 2013.)
To place and require a burden on the individual social worker to account for why this treatment modality is justified by necessity of extenuating circumstances also raises the issues of parity and access. Providers familiar with the issue of mental health parity will hopefully see the parallels here. Clinical social workers for example may become more reluctant to work with patients requiring adaptive technology if they realize that they could be held to a higher level of scrutiny and documentation than their counterparts who do not use online technology. Even though the Board would possibly deem those circumstances “extenuating” it would require an extra layer of process and bureaucracy that could have the side effect of discouraging providers from taking on such patients.
Insurers such as Tricare and the providers in the military are increasingly allowing for reimbursement for telemedicine; and videoconferencing software is becoming more encrypted and in line with HIPAA. While these should not be the reasons that drive telemedicine in social work, we should consider that a growing segment of the population finds it a reputable form of service delivery.
Such policies require input from people with expertise in clinical practice, the law, technology, and the integration of the three. When I asked about whether any members of the Board had experience with the use of different newer technologies in clinical practice or how to integrate them, I was informed that “the Board is comprised of members with diverse backgrounds. They have reviewed the policies and procedures for electronic means for many other jurisdictions as well as the NASW and ASWB Standards for Technology and Social Work Practice in addition to the policies set forth for Psychologists, LMHC’s and LMFT’s in MA.”

The NASW policy which I believe she is referring to was drafted 8 years ago in 2005. For context, it was drafted 5 years before the iPad in 2010, 2 years before the iPhone in 2007, and 4 years before the HITECH act in 2009. In fact, the policy I reference says nothing about limiting technology such as online therapy to “last resort;” rather it encourages more social workers and their clients to have access to and education about it. That professional organizations may be lagging behind the meaningful use and understanding of technology is not the Board’s fault. But to rely on those policies in the face of recent and evidence-based research is concerning. If the Board does wish to be more conservative than innovative in this case, I’d actually encourage it to consider the policy adopted by the Commonwealth’s Board of Allied Mental Health Professionals at http://www.mass.gov/ocabr/licensee/dpl-boards/mh/regulations/board-policies/policy-on-distance-online-and-other.html which in fact does not make any mention of setting a criteria of extenuating circumstances or potentially intimidate providers with the requirement of justification.

I hope the Board listens to my concerns and input of research and experience in the respectful spirit that it is intended. I am aware that I am commenting on a policy that I have not even seen, and I am sure that the discussions have been deep and thoughtful, but I know we can do better. As a lifetime resident of Massachusetts, I know we take pride in being forward thinkers in public policy. Usually we set the standard that other states adopt rather than follow them. I invited the Board to call upon me at any time to assist in helping further the development of this policy, and reached out to state and national NASW as well. I hope they take me up on it, but I am not too hopeful. I had to step down from my last elected NASW position because I refused to remove or change past or future blog posts.

If you practice clinical social work or psychotherapy online, it’s 3:00 AM: Do you know what your licensing boards and professional organizations are doing? Are they crafting policies which are evidence-based and value-neutral about technology, or are they drafting policies based on the feelings and opinions of a few who may not even use technology professionally?

This is a big deal, and you need to be involved, especially if you are pro-technology. The research from Pew Internet Research shows that people age 50-64 use the internet 83% of the time, about 10% less than younger people; and only 56% of people 65 or older do. These older people and digital immigrants are often also the decision-makers who are involved in policy-making and committees.

If you don’t want to practice online, you may bristle at this post. Am I saying that older people are irrelevant? No. Am I saying that traditional psychotherapy in an office is obsolete? Absolutely not. But I am saying that there is a backlash against technology from people who are defensive and scared of becoming irrelevant, and fear does not shape the best policy. Those of us with experience in social justice activism know that sometimes we need to invite ourselves to the party if we want a place at the table.

And with government the table is often concealed behind bureaucracy and pre-digital “we posted notice of this public hearing in the lobby of the State House” protocols. My local government is relatively ahead of the curve by posting minutes online, but I look forward to the day when things are disseminated more digitally, and open to the public means more than showing up at 9:30 AM on a work day. If they allow videoconferencing or teleconferencing I will gladly retract that.

At its heart, divisions of professional licensure are largely about guildcraft: They regulate quality for the good of the whole guild and the consumers who purchase services from guild members. They establish policies and sanction members of the guild as part of establishing and maintaining the imprimatur of “professional” for the entire guild. They develop criteria both to assure quality of services and to regulate the number of providers allowed in the guild with a certain level of privileges at any time: LSWs, LCSWs, and LICSWs are the modern-day versions of Apprenctice, Journeyman and Master Craftsman. This is not to say guilds are bad, but it is to say that we need more of the senior members of the guild to advocate for technology if they are using it.

Too often the terms “technology” and “online therapy” get attached to term “ethics” in a way that implies that using technology is dangerous if not inherently unethical. That’s what I see behind the idea that online therapy should only be used as a “last resort.” We thought something similar about fire once: It was mysterious to us, powerful and scary. So were books, reading and writing at one point: If you knew how to use them you were a monk or a witch.

Technology has always been daunting to the keepers of the status quo, which is why you need to start talking to your policymakers. Find out what your licensing boards are up to, advocate, give them a copy of this post. Just please do something, or you may find your practice shaped in a way that is detrimental to your patients and yourself.

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References

Birgit, W., Horn, A. B., & Andreas, M. (2013). Internet-based versus face-to-face cognitive-behavioral intervention for depression: A randomized controlled non-inferiority trial. Journal Of Affective Disorders, doi:10.1016/j.jad.2013.06.032

Funderburk, B. W., Ware, L. M., Altshuler, E., & Chaffin, M. (2008). Use and feasibility of telemedicine technology in the dissemination of parent-child interaction therapy. Child Maltreatment, 13(4), 377-382.

Harris, E., & Younggren, J. N. (2011). Risk management in the digital world. Professional Psychology: Research And Practice, 42(6), 412-418. doi:10.1037/a0025139

Mitchell, J. E., Crosby, R. D., Wonderlich, S. A., Crow, S., Lancaster, K., Simonich, H., et al. (2008). A randomized trial comparing the efficacy of cognitive–behavioral therapy for bulimia nervosa delivered via telemedicine versus face-to-face. Behaviour Research & Therapy, 46(5), 581-592.

Nelson, E., Barnard, M., & Cain, S. (2006). Feasibility of telemedicine intervention for childhood depression Routledge.

Trief, P. M., Teresi, J. A., Izquierdo, R., Morin, P. C., Goland, R., Field, L., et al. (2007). Psychosocial outcomes of telemedicine case management for elderly patients with diabetes. Diabetes Care, 30(5), 1266-1268.

Filed Under: Gamer Therapy Tagged With: activism, aswb, behavior change, boards, building your business, digital literacy, e-therapy, education, guilds, HMOs, insurance, licensure, managed care, massachusetts, mental health parity, middle ages, NASW, policy, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, ROI, social justice, social media, technology, telemedicine, therapy, Web 2.0

You’re The Reason Building Your Business Is So Hard

May 31, 2013 by langloimsw 22 Comments

Recently I was asked by a student to take some time and talk with her about her career options. She was trying to plan for her career post-graduate school, and struggling some with the vicissitudes of a graduate program in mental health. Such vicissitudes, once you commit to studying in the field of your choice, are out of your control. Students are often told what to learn, how to learn it, where to intern, and what kind of internship they can have. Want to learn psychodynamic theory? Sorry, school X doesn’t believe in it, so if you go there there may be one or no mention of it in your foundation work. Want to work at a leading hospital? Sure, you and 100 other students from the schools in your area; so apply, but don’t count on it. So, in graduate school, students like my student often have to like it or leave it.

This disempowers the budding therapist in many ways, not the least of which is that it conditions her to take her cues from others even beyond graduate school. It is hard to learn that you have the power to build your career and business after having been taught that the schools, placements and agencies are the ones who make the rules.

If you are out of school, you have more power than you think, and therefore more responsibility than you may want.

Many therapists want to avoid taking responsibility for their businesses. No sooner do we get out of a school or agency then we start to recreate an agency of our own devising. We create our own set of disempowering expectations, and there are usually plenty of people around to collude with us in this. I call them disempowermentors.

Disempowermentors in the mental health field are the ones that tell you all sorts of rules about how things work. They’ll tell you you can’t build a practice without being on insurance panels. They’ll tell you you need to work in our field for 10 years to build up a reputation before you can open a practice. They’ll tell you you should sublet a few hours and not jump in to a full-time practice. None of these things are true, but most of them are usually fear-based. They are usually the way the disempowermentors did things, either because they recreated their own inner agency and/or because they listened to disempowermentors themselves. If my student isn’t careful, she’ll end up listening to one of these folks, and set herself and her future business back a few years. She’ll have a structure, but it will be one that restricts her choices rather than increases them.

Take a look at who you are listening to: Are they disempowermentors? (One sure clue is that disempowermentors almost always look more tired than happy, more miserable than inspirational.)

One example of someone whom the disempowermentors would say is doing everything wrong is my consultee Lindsey Walker. Lindsey is going right into private practice after finishing graduate school. Lindsey is working on building a full-time practice. Lindsey isn’t in any insurance networks. And things are starting to happen for her. This is largely because Lindsey is very creative and responsible. She has started a blog, Waking The Image, which combines photography and essays on psychodynamic theory. She also just finished writing her first e-book Love Over Trauma: Healing With Your Partner on helping couples recover when one or both of them has trauma in their past.

None of these projects occur in a separate pocket universe: Lindsey works daily on these projects and other tasks that we come up with in the course of our work together. I send her a list of things she’s committed to, and within the next several days she does them. That is why her work is slowly but surely getting noticed and her practice growing. She isn’t waiting passively in her office sublet for the phone to ring. She isn’t waiting passively for insurance panels to accept her, or accepting the fee they want to pay her. Lindsey knows that she is responsible for the success of her business. She is investing time and money into building it, not subletting 2 hours somewhere cheap and hoping she’ll get a client or two after her “day job.” Lindsey made the decision to make building her business her day job. I should also mention that she is not independently wealthy, and that this venture has been a risky and courageous one.

So take a look at your career. Are you happy with it? Is being safe worth it? Are you investing time and money into building your business? Are you taking risks?

If you answered no to those questions, then you are the reason building your business is so hard. You aren’t in grad school any more. You choose to apply for a job, accept it, or strike out on your own. You choose whether to make building your business your day job and make whatever sacrifices you need to make to do that. You decide whether or not to invest in an office, a consultant, or other business expenses. You decide to wait passively for someone to pay you a fraction of your fee, or actively market and network for hours and days and weeks. You decide whether to contribute a blog, book, talk or idea to the world like Lindsey; or not to contribute anything without permission from somebody else. You decide whether to confuse worry with effort and wishing with doing.

Lots of things are possible for you. Owning your own business is neither easy or safe, but it is possible. It takes lots of effort and doing. It’s risky, but no one is making you do it or holding you back. It’s up to you to decide.

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Filed Under: Gamer Therapy Tagged With: behavior change, building your business, digital literacy, disempowermentors, education, HMOs, insurance, managed care, marketing, mindfulness, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, referrals, ROI, self-promotion, social media, therapy

What It Means To Make A Referral

January 7, 2013 by langloimsw 4 Comments

To speak with a relative stranger about the most intimate details of one’s life is an incredibly daunting prospect for many psychotherapy patients. No matter how guarded a patient may be, she or he is daring to be incredibly vulnerable as well. Often the only thing that can make this beginning possible is an appropriate therapy referral. And yet never before has it been so easy for us to make a horrible or thoughtless referral to these brave souls.

It was hard enough when managed care began to shape the behavior of therapists to focus on insurance as being the number one or only criteria to make a referral. But now technology has made it even worse. Readers of this blog know that I am a great fan of technology in general and social networking in particular, so it may come as a surprise to hear me say this; an explanation is in order.

Recently I began to get emails from various therapists with the subject heading “Are you accepting new referrals?” or “Referral for you.” In the past I have found those questions a nice compliment. But these emails were actually invitations to join something called Referral Key, a small business referral network. The message went like this:

If you’re taking on new clients, I’d like to include you in my private referral network to send you business leads.

Please accept my invitation below. Thanks!

Here’s the problem, none of the people who sent me these emails knew me in a professional capacity as far as I can tell. We had never shared a patient, attended a fellowship together, worked at the same agency or supervised trainees at the same place. The only qualification these people would know I had if I accepted their invite was that I wanted more business.

That’s not how you make a good referral.

Look, referring a patient to someone is risky enough when you do know the therapist or the patient. Risky because we have never experienced what it is like to sit with the colleague as a patient. But at least we have some other information to go on. The nature of therapy requires that we be as thoughtful about referrals as possible.

In my experience with trainees and consulting to therapists I have come across a lot of marketing information on how to get referrals, but not a lot of clinical info on how to make them. So here are my suggestions on when and how to make a good referral. Keep in mind that these tips are a combination of my experience, opinions and pet peeves. Between emails, listservs, social networks, etc., I see a lot of different ways therapists do it.

1. Don’t treat a referral as a consolation prize. If you get a call from a patient who says they were referred to you by their insurance, and you are not accepting new patients, don’t feel pressured to offer them another name. Ideally, if you have time to offer them an initial consult you may get enough information to make a suitable referral. If they can come in, you can discuss their presenting problems, therapist preferences in terms of gender, experience, etc. If you offer free phone consultations (which I discourage in general,) you can speak with them over the phone at enough length to get a sense of the patient’s needs. For a thoughtful referral, my experience is that this takes 30-45 minutes. looking online and saying, “Jane Doe appears to be in your network and I’ve heard good things about her” may be sufficient to assuage your conscience but is not sufficient to be a solid referral. Jane may be a whiz at adult ADHD, but if the patient was referred to you for your expertise in PSTD you may have no idea whether Jane has interest or expertise in both.

2. Avoid referring to therapists who “do it all.” I never refer to a therapist who treats ages 3-80 for issues ranging the breadth of the DSM-V. The USDA deals with chunks of meat on a conveyor belt, we don’t.

3. Disclose the extent or limitation of your knowledge of the referral to the patient. If you trained with the person and think highly of them from the way they discussed their work, say that. If they are someone who responded to a listserv request you made and you know nothing about them or their work, say that. Patients trust us to give them expert opinions, and if your expertise is limited the burden of disclosing that is on you.

4. When soliciting a referral, keep it brief and salient. Don’t pepper the listserv or discussion boards with identifying information or your subjective impressions. Age, presenting problem and therapist preferences (gender, takes X insurance, CBT) are enough. So often I see referrals for someone seeking a therapist for a patient who is “a lovely, very insightful young man who would be a delight to work with.” This is more of a sales pitch than salient data. None of your colleagues are probably hoping to work with horrid, clueless people who are a misery to work with, now are they? Nor do we really need to know that the referral is for the daughter of a good friend of yours. If this is a referral that will involve collaboration (such as one member of a couple you are seeing) by all means offer to share more information if the referral works out. But in the meantime, just the facts.

5. When possible, get feedback and use it to inform your future referrals. If you referred to a colleague to treat one of your individual patients for couples therapy, ask them how it is going or went. Please take this information seriously and do not dismiss it as transference. It may be transference, but remember your alliance is with the patient and erring on the side of caution. In my time I have had folks give me feedback that the people I referred to didn’t listen, feel asleep during a session, took their spouse’s side, smelled of alcohol, and a myriad of other concerning statements. Do I know for a fact that any of these stories were true? No. Do I plan on risking referring a patient to one of those people again, absolutely not. If the person you refer to is difficult to reach or collaborate with, bear that in mind for future referrals.

6. Talk to your colleagues. Ask them whether they are taking referrals, or what kind of patients they see. Ask them what their expertise is if you are unsure. Send them an email with brief and salient information asking if this sounds like someone they’d enjoy working with. And absolutely send them a note if you give their name as a possible referral.

7. If you don’t have or want to take the time to make a solid referral, then don’t make one at all. Too often our colleagues try to come up with a name rather than say, “I’m sorry I can’t help you.” Our graduate programs rarely train us to say that. But better you say that than misunderstand what a referral truly is. A referral is a thoughtful recommendation to a patient for a clinical treatment of serious concerns. If you don’t have time to give it sustained thought, understand the concerns or help needed, don’t give a referral.

Above all, please keep in mind that social networks are great for many things, and referring patients is not one of them. If the only thing you know about a therapist and their work is that they are in your “network,” what kind of qualification is that? Don’t confuse networking, marketing, or chatting with referring someone to therapy. If you were looking for a therapist and someone said, “I got an email the other day from someone saying they are taking on new patients,” would that be sufficient for you to make an appointment? Just because I’m in your Contacts or LinkedIn group doesn’t mean I am any good at therapy in general or for a patient in particular. I could be a complete wingnut.

Do you really want to take that chance with someone’s mental health care?

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Filed Under: Gamer Therapy Tagged With: building your business, digital literacy, insurance, managed care, marketing, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, referrals, social media, technology, therapy

How to Get Taken Seriously as a Mental Health Professional

August 8, 2012 by langloimsw 8 Comments

Many therapists looking to start or grow their private practice often wonder the same question when they are starting out: How do I get referrals? If you can tolerate a mild rant, I may have one answer for you.

Let’s look at this concern through a tried and true mental health paradigm. First, we take a symptom, and then we look at the underlying conflict that the symptom represents.

So what’s the symptom? That’s easy, head on over to LinkedIn and take a look at several profile pictures of colleagues. Go ahead, I’ll wait. What did you see? When I looked I saw some professional headshots, but more of the following:

blank photos
top of head/ chin cut off
people in front of a car
waterfalls
tank tops
the “I’m holding my phone camera at arm’s length” shot
at a party
graduation gown
flower
too dark to see
wearing sunglasses
skiing

If you want to generate referrals, this may be a problem. Some colleagues may have a different opinion or be too diplomatic to say this, but let me not mince words. If you don’t have a professional headshot it is doubtful I will refer to you. I don’t send people to waterfalls for psychotherapy. I suspect people wearing shades of paranoia or vampirism. I envy people who can ski much too much to ever want to help them grow their business. Cars in photos are either nicer than mine or too shabby, triggering too much judgment either way. And party-goers scare me. 😉

My experience as a consultant has been that these headshots are symptomatic of one of two scenarios:

1. You don’t take social media seriously. In this day and age, our potential patients want to see us before they see us. They often do their research by checking out our online presence. If you go on LinkedIn for example, you may find that several people viewed your profile this week. A picture is worth a thousand words. I have seen great head shots in black and white, or even avatars for online therapists, so it doesn’t have to be a standard color shot. But the way technology works now, whatever picture you choose will most likely attach to your emails, tweets, blog comments, posts, and feeds of all kinds. There are exceptions to this, like my colleague Social Jerk, who needs to maintain a tight hold on her anonymity to allow for her to create such creative and satiric posts about social work. But if you are not trying to be a satirist, but rather grow a therapy practice, this will not work for you. And if you’re on Twitter, please don’t be an egg. When I need to jettison followers to follow additional people, the eggs are often the first to go. Accept that social media is the point of professional first contact with your colleagues and customers. Take it seriously.

2. You don’t take yourself as a therapist and businessperson seriously. Anyone that has read this blog or chatted with me at a workshop can probably tell you that I am neither dour nor constantly serious. I certainly think there is a lot of room in our profession for humanity, play and creativity.

That said, we are in the business of providing treatment for serious concerns, working with people who have a range of predicaments. We assess for suicidality, psychosis and trauma. Your patients come to you with vulnerability and hope that you will help them create profound change, recovery and healing in their lives, maybe even help them stay alive. If you think that therapy is just two people in a room chatting, then by all means keep the beach picture.

To get a professional head shot requires investment of your time and money. It is a business expense. If you are unwilling to invest in a professional image to represent your business concern I suspect you are not ready to own and run a business. If you are unwilling to invest the time to look through your existing photographs and select one (if you have it) that presents a professional demeanor online then I suspect you are not ready to own and run a business.

Now I know that the term “professional” photo is vague and subjective. I am not saying that you need to be in a suit and tie. You can be a play therapist and have affect like my colleague Charlotte Reznik. But slapping up a blurry photo of you near a palm tree sends the message that you can’t be bothered to represent yourself or your brand. And in business we need to be concerned about our brands, even as therapists.

Look, I’m not saying these things to hurt your feelings. I really want you to succeed, and I know that there are a lot of people out there who need your help. That’s why I suggest that the photo is the symptom of an underlying issue, which is the difficulty to take either technology or your business seriously. If you have taken time and consulted with trusted colleagues and have come to the conclusion that “I want potential patients to see me as someone blurry whom they could go skiing with” is your brand, and that the head shot is a conscious and intentional image to brand yourself online than you have my blessing.

If not, get thee to a photographer.

If you are interested in participating in a small group supervision experience, you may want to check out the Supervision Package I’ll be offering this fall. You can find out more about it here.

Like this post? There’s more where that came from, for only $2.99 you can buy my book. I can rant in person too, check out the Press Kit for Public Speaking info.
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Filed Under: Gamer Therapy Tagged With: building your business, education, linkedin, managed care, marketing, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, referrals, ROI, self-promotion, social media, technology, therapy, twitter, Web 2.0

The Perilous Price of a Good Living

June 30, 2012 by langloimsw 6 Comments

Recently I had the opportunity to talk with a group of young clinicians, and very bright young clinicians at that. We were discussing the role of class in psychotherapy, and how to understand it psychodynamically. I was demonstrating to them how difficult it was for therapists to talk about money, by asking each of them what they would set their fee at. The majority of them were extremely reluctant to give a dollar amount, and it was striking to me that the dollar amount was almost to a penny what a leading insurance company set their allowed fee at. But the most troubling response to me was “enough to make a good living.”

I imagine you’ve heard this phrase frequently–like me, maybe you’ve said it yourself from time to time. It is a throwaway statement, which tells you nothing really about what kind of living a person wants or how much money they need in a capitalist society to make it. Amongst professionals it is the “Whatever” of salary statements.

Pushing folks, I usually get a comment about “having a good home,” “enough to comfortably support my family,” etc. These are similarly throwaway statements, but they indicate to me what continues to be considered socially acceptable when talking about money in mental health. It is ok to want to make money if you only use it to support and shelter your family. Maybe a vacation, but let’s not push it. In her 1994 article “Money , Love, and Hate: Contradiction and Paradox in Countertransference,” Muriel Dimen refers to “Puritanism’s conflict, in which hard work and thrift are valued, but their material rewards may not be enjoyed.” In other words, what most psychotherapists consider a good living.

Often when working with consultees who are giving everyone a sliding scale fee and often acting out in their countertransference as a result of it, I work with this Puritanism, rather than combat it head on. I’ll ask them to take a photo of their children, partner, any loved one who depends on them, and keep it visible to them in their office from where they usually set their fees. These are the people, I tell them, who will go without because you have issues about your fee. You may think you are being noble by sliding down all the time, but these people are bearing the burden of your nobility.

Am I saying you shouldn’t have a sliding scale fee? Well yes and no, actually. I certainly have 2 slots where I slide my fee. Exactly two, because that is what I have determined in my business plan I can afford. And if someone is going to be offered one, I always go over with them their financials. So if you have a business plan, and if you can have a concrete conversation with your patients about how much money they make and expend in their life, you have my blessing, you can have a sliding scale. But if you have not taken a good look at how much YOU need to make, what your plan is to earn money and have pro bono, and if you can’t bring yourself to talk about a patient’s finances, I don’t think you should have a sliding scale. In fact, I’d suggest you should really only work in an agency and/or cap your fee at what Insurance Company A tells you are worth.

Because that in fact is how this got started in many ways. We lament how exploitative insurance and public agencies are, but the reality is they provide us with a buffer from the conflict of having to talk with our patients about money. Many of us make the third party the “bad guy,” because we don’t want to sully our therapeutic conversations with the topic of money. Sex, sure. Incestuous fantasies or homicidal impulses, no problem. But cash? Forget it, that’s too tough to talk about.

Like many of you, I am very pleased that we have passed the Affordable Care Act this year, but I am equally happy that I don’t have to be limited to seeing patients via insurance. This is the difficult paradox many of us try to keep secret: We want everyone to have access to health care, but we don’t want our incomes capped by those rates. Not everything our patients come to see us for is medically necessary treatment. Some of it is quality of life and personal insight, and maybe our patients should pay for that themselves. This may sound like a two-tiered system, and that’s because it is, and in my opinion you will see this two-tiered system get acted out as soon as we switch to a medical home, global payment model.

For me a good living is not having a home and enough to support my family. I want an XBox, and an iPad, and someone to help me clean my house, and vacations and my Starbucks as well as some other things that even I am reluctant to admit. I want things that exceed a comfortable lifestyle. Maybe you want these things as well, or a yoga retreat, a summer home or a pony, I dunno. Take a look at cable TV sometime, and ask yourself why there is such a proliferation of reality TV surrounding making/winning/wheeling/dealing so much money. Our voyeurism betrays our fantasies. But Priscilla or Myles, our inner Pilgrim, still trips us up, and we are afraid to admit exactly what we want as a good life.

In case you think that I have exorcised Myles from my psyche, let me assure you I still struggle with wanting, having and making money. In a way, my evangelizing on this could be a reaction formation. But it is a feeling, and I can’t let a feeling get in the way of understanding myself and being ethical.

You see, I’m with Plato and Socrates on this one. Socrates defined the good life. The good life is the examined one, the life lived in pursuit of knowledge and consciousness. Socrates doesn’t really talk about money when he talks about the good life, but he does make some interesting points about virtue and how knowledge leads our virtuous behavior. Not what you feel, but what you know.

Sounds simple, but it isn’t. In Meno Socrates describes how important perplexity is in the process of attaining knowledge, and hence ethics. Perplexity is struggling with the contradictions to try to make sense of them, like “I want to help people,” and “I want the iPad 3.”

Periodically I re-evaluate what I want in my life, because my wants, my needs and my financials change. My financial limits are clear to me, and not always in accordance with those of others. For example, my billing company thinks that I shouldn’t allow balances higher than $200 to be carried. I consider $400 to be my limit. It is up to me to struggle with and get clarity on these things if I want to own and run a business. And money runs through and beneath my business. If I want to take a day off, my boss is pretty stingy. I rarely take sick days. I have a 48 hour cancellation policy that is much more rigid than many colleagues, but not as rigid as the week cancellation policy of some. I can live with all of that, I’ve thought it through. I don’t hide behind the vague salve of “making a good living,” I struggle with the perplexity of my needs and wants, the moral implications of them, and how to live ethically in the context of that struggle.

In many ways, that’s what I call a good life.

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Filed Under: Gamer Therapy Tagged With: behavior change, building your business, HMOs, insurance, managed care, marketing, mental health parity, private practice, psychodynamic, ROI, social justice

Thinking, and Just Thinking

March 20, 2012 by langloimsw 5 Comments

Originally I was going to title this post, “How to Make A Million Dollars as a Therapist Without Ever Having to Talk About Money.” And if I was just concerned about driving traffic to my blog and business, that would be the title. Because there are a lot of our colleagues out there who want to have a very successful business without having to deal with the sordid matter of coin. I used to think this was the number one reason that psychotherapists have a hard time being successful as entrepreneurs. I used to read, and agree with, several psychodynamic articles that have been written by colleagues which talk about how we feel shame around money, project our devaluation of ourselves by refusing to spend money on coaching or supervision, and have difficulty set fees and enforcing missed appointment charges with our patients because we feel that we don’t deserve to make money for our work.

I still think those are big hangups a lot of us have, but recently I’ve started to suspect that an even bigger one is our fuzzy thinking about thinking.

Therapists as a whole love to think. We like thinking deeply about our patients. Many of us love working with emergent adults in a large part because their neurology has finally blossomed and they are starting to reflect on their thinking. We often enjoy studying and debating the thoughts of major theorists. We even see the value of self-reflection in our work with patients. We like to think about others, the thoughts of others, our thoughts about the thoughts of others, and what great thinkers have thought about the thoughts of others and our thoughts about them. Boy, do we like to think about thinking.

Now I am no exception to this. I see an immense value to thinking, in fact I schedule time during my daily work week where I walk around the Charles and think. During this time I don’t take calls, I don’t check email, I don’t make appointments. I think. I intentionally schedule it during the day to remind myself that thinking has a critical place in my work, and has as much if not more value than a billable hour. And I will often lament to colleagues in academic settings about the need for more critical thinking skills. I’ve had colleagues critique my wanting more theory classes at BC by saying, “these students want classes that give them practical tools that they can use,” to which I respond, “how about thinking? That seems like a pretty good tool to me, when did we stop considering it practical?”

So I am not intending to come across as anti-thinking here. But I have noticed over the past several years who succeeds in getting their private practices off the ground and thriving, and who doesn’t. And the ones who fail are usually the ones who come to consult with me, or then need to “think about it.” I’m very concrete when I talk with consultees, and if they are in job crisis I call it that. I’ve worked with people whose incomes have shrunk by halves over the past several years. I tell them what has worked for me, and offer suggestions, and the suggestions require things like calling people to network or EAPs or insurance providers every day or write a business plan, or any number of other things.

They listen and say they’ll think about it.

Some people will make a lot of money off of those folks. There are dozens of people out there who can tell you how to “visualize” your ideal client, “ideate” abundance, or give you a 5 point plan to success. I’m not one of those people, and so sooner rather than later the conversation peeters out. Because they have a hard time moving into doing something other than thinking and talking. Maybe they’ll write a blog post or tweet a few times, but they get discouraged, because I’m not going to waste their time. This isn’t therapy. I’ll tell you what I think you ought to do. You don’t have to do it, but I don’t have a second set of things I think you ought to succeed in your business. So if you don’t want to do them, we really don’t have a lot more to talk about.

A lot of therapists, myself included, like to try to think and talk our way out of everything. And many things can be significantly impacted by strategic thinking, and thoughtful process. But eventually you have to do some other form of work if you want to be in private practice. We have more autonomy as sole proprietors, but we also can’t just sit in an office hour after hour “just helping people.” This is actually the fantasy I often hear expressed by colleagues, “I just want to help people,” as if the nobility of that entitles one to not have to exert any other effort.

One of my friends has a mentor who frequently says, “don’t confuse worry with effort.” Much of the time I think we confuse worrying with deep thinking, and even more so with taking other forms of action. We think if we worry about a problem either alone or with another that somehow that “counts” as having done something. The idea of sustained effort truly alarms us. I’m talking about me too here. One of the reasons I have a set time in my week to think about things is so that I contain that urge to think fretfully and know that there is a time and a place for me to think about stuff. And then I go on to other activities that are required of me during the day.

Another reason the Charles river is such an important place for me around this is that it is where I run. During the week I walk along it and think, and on the weekends at least once I run along it. But, and this is key, I don’t go to the Charles and think about running.

I can really only tell you what works for me, and incessant and indiscriminate thinking does not work for me, or my business. If someone tells you that there is an easy, simple way to succeed in creating and growing your practice, I encourage you to be skeptical. Creating and growing your business involves taking risks, trial and error, and most importantly sustained effort that is not entirely cerebral. My experience has taught me that you won’t think your way into a successful practice, but you may succeed in thinking yourself into a bankrupt one.

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Filed Under: Gamer Therapy Tagged With: behavior change, building your business, business, managed care, marketing, mindfulness, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, referrals, ROI, self-promotion, therapy

How To Get An Epic Supervisor

January 25, 2012 by langloimsw 6 Comments

Education shapes our expectations of life and work, and education as it stands currently always involves giving up some degree of personal power. When we’re in elementary school we need to ask permission to leave to use the bathroom. In high school we need to show up at times diametrically opposed to our circadian rhythms. At college we have required course to complete our degree. And in graduate programs for clinical psychotherapy we often have limited to no control over who our supervisor is going to be.

And then when we graduate, we take our cue from licensure boards to a large extent. Sadly, license requirements shape our expectations of supervision. We see it as something we have to have in order to get our license in X number of years. I have noticed that there is a sharp decline in people buying supervision after they get their independent licensure, which does not mean that there is a correlative decline in our people needing it.

So today I want to talk about how to pick a good supervisor for you to have ongoing clinical supervision. If you are still in pre-independent licensure this can be an especially daunting experience, but also an incredibly freeing one. To be clear, you don’t have to purchase private supervision from anyone you don’t want to work with! Read on for some tips:

1. You often get (or don’t get) what you pay for (or don’t pay for.)

If your agency offers you a good supervisory package for free that is great. One place I supervise at provides employees and interns with a free secondary supervisor. Secondary supervisors are the ones who can usually help you most with integrating theory and practice and discussing difficult cases. Most primary supervisors I know may have good skills and an interest in doing the same, but they don’t have the time. Their role has become reduced in the age of managed care to helping you learn the ropes about paperwork, facilitating your first emergency room or child protective referrals, and being held responsible for holding you responsible for productivity. So although these hours count towards your licensure they don’t necessarily deepen your practice for lack of time, not skill.

So now you have some choices. You can take a fellowship or position at an agency that provides secondary supervision, or you can buy it privately. Don’t get caught in thinking it is an entitlement, because those days are gone. Yes, we’re underpaid as a profession, but I suggest you think of good supervision as a benefit valued at between $7200-$9600. If Agency A offers that, but pays less $5,000 less than Agency B, which doesn’t, you are getting a better deal at Agency A.

2. You may already have met your supervisor, but don’t know it yet

If you are one of the many folks who decides to buy supervision privately, take some time to think about the people you’ve worked with already. Did you enjoyworking with your first year placement’s supervisor? Call and ask her if she offers private supervision. Did you love a certain course in grad school? Call and ask him if he does supervision. If they don’t, ask if there are any people they can suggest. Think back to guest lecturers, colleagues you enjoyed working with, that alum you met at an event.

3. Do your research

In this day and age, everyone should have a LinkedIn profile (more on that in a bit.) Mine includes several recommendations from past or present supervisees. Make sure you Google your potential supervisor prior to making an appointment. Yes, Ms. Jones may have her licensure, but if you are interested in providing LGBT-affirmative therapy and she works at the local conversion treatment center, wouldn’t you like to know that before wasting both of your time?

When you contact a potential supervisor, hopefully they will offer to provide you with a reference of another past or present supervisee. If they don’t, ask.

Some of the old guard psychodynamic folks may object, saying that that contaminates your supervisory experience. To which I say, there will be plenty of transference that comes up regardless, and that the focus of supervisors should be on practicing radical transparency, not generating a absolutely blank screen. Supervision often resonates with therapy, but it is NOT therapy. If a supervisor comes off as seeming like a Freudbot, this may indicate a difficulty shifting cognitive frame sets from supervisor to therapist.

4. Know what is important to you

You can learn something from everyone, I truly believe that. However, when I look for a supervisor, I look for someone who provides psychodynamic-oriented supervision. That’s what I do, what I like, and why I became a therapist. If you are a solution-focused or CBT practitioner, get someone who is expert and experienced in that.

If someone says they are “eclectic,” run away. Far far away. If they can’t describe some of the several areas of their interest or competence to you, chances are they are being either vague or seductive. Yes, I said seductive. Supervision is a business prospect, and many people focus on landing a new supervisee to the detriment of both of them.

5. Beware of freebies, private supervision starts with the fee

I’m going out on a limb here, but I strongly discourage freebies. My Contact page warns away the brainpickers. These are the people who want to get something for nothing, and say, can “I just pick your brain for a second?”

No, you may not.

There is a lot of free content I’ve put out there that people have access to, but this is also my work and I need to be paid for it. So if you have done your research, hopefully potential supervisors will have papers published, posts online, lectures, recommendations. If not, please see item 6.

I have strong opinions about this, because I think it shows potential supervisees how to have professional boundaries and value their work. If you are doing supervision to “give back” at a reduced fee, that’s fine, as long as you let the supervisee know that you are reducing your fee and let them know the full fee. But be honest with yourself about this, are you doing it to gratify your self-ideal of social justice, or because you secretly believe that you aren’t worth the full fee, or some other reason?

If you are a potential supervisee, consider this: Do you need someone to help you learn to be a more noble person, a better clinician, and/or a more savvy businessperson? Will having a reduced fee lower your expectations of yourself and the supervisor? And would you like to charge no higher than the reduced fee you are being offered?

If the answer to the last is no, be careful, because this may be a set-up for resentment on your supervisor’s part, and you may both suffer from unconscious false pretenses.

Speaking of fee, I walk this walk, and when I negotiated my fee with my supervisor I negotiated to pay more, because I knew that I would have a harder time later if I didn’t. We then had a great conversation about the limits of this, because obviously she gets to set her fee not I. But it caused her to re-evaluate and raise her fee somewhat, and modeled for me her integrity, flexibility, and willingness to listen and learn. And each time I raise my fee, I bring this up again, and each time the supervision is the richer for it.

6. If you want supervision around private practice, stay away from technophobes.

I strongly maintain that to have a practice in the 21st century you will need to have an online presence, some technological savvy and the willingness to learn about it to work with people from the 21st century. This is even more true in a private practice, where marketing is moving more online every day.

I once had a couple of sessions with a supervisor I was considering starting work with. This was a world reknowned clinician, whose work I respect immensely. In the time between our first and second appointment I included her on my newsletter. Our next appointment she expressed how “astonished” she was that I would contact her that way, and wondered if I was sabotaging the supervision. Fortunately I have been in many supervisions and have a strong ego. That was our last appointment.

I suppose I could have chosen to stay and explore this, but that seems more her issue than mine. I want to have a practice that focuses on Web 2.0 and psychodynamic therapy, i.e. integrating, not pathologizing them. And if those were her boundaries, fair enough. But I’m paying for a service, and I’ll take my business to my current supervisor, who is very professional, very grounded in psychodynamic theory, and subscribes to my newsletter, remarking on every issue.

7. Kick the tires

Having read this, you may be thinking, “I don’t agree,” or “that’s not what I want,” or “what a pill he is!” If so, that’s great! Because that means you have some idea what you are or aren’t looking for. Or you may be thinking, “right on!” One thing my supervisees can probably tell you is that what you read here and what you get in supervision with me are pretty much the same thing. And it seems to be working well for all concerned. You aren’t in grad school anymore, you get to pick and choose your supervisor.

It is okay to try out a few supervisors before deciding. Pay attention to those first few appointments, when you and your supervisor “relax” into the supervision a bit. Do you notice drastic changes from the first week(s)? Do you look forward to supervision, dread it, or find yourself not caring either way? Ask yourself, and your supervisor, how the supervision is starting off. If your supervisor does not bring up how to get the most value out of your supervision in the first few months, bring it up yourself.

If you are having mixed feelings about a supervisor, don’t be afraid to bring that up. But if you can’t bring it up, or choose not to, don’t feel obliged to stay. Supervision is a long, intense and valuable process. No less than your professional development is at stake. Choosing wisely begins with remembering that you have a choice.

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

Filed Under: Gamer Therapy Tagged With: building your business, education, licensure, managed care, marketing, oliver twist, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, ROI, self-promotion, supervision, therapy, Web 2.0

The Uses of Disenchantment

January 12, 2012 by langloimsw 6 Comments

Magic fulfills the wish that we could have powers to be beyond who we sadly suspect we are. As children, magic explains the inexplicable nature of external forces (i.e. parents, teachers, death) and internal ones (unconscious drives, nameless attachments, inconsolable sorrows and consuming rages.)

Anyone who plays WoW, Elder Scrolls, or Dungeons & Dragons, knows that enchanted weapons and armor are valuable items to be gotten. They raise our stats, make us stronger, more intelligent agile, or resistant to harm. They fulfill the wish that we could be more than we are.

That being the case, the profession of Enchanting is a very valuable one to master. To do so is to be able to craft our own items for use or to sell. And to master the skill requires not only enchanting practice, but also the act of disenchantment.

Disenchantment is the breaking down of an enchanted item into its component reagents. In Skyrim this consists of taking the enchanted item and destroying it, which allows you to discover the enchantment. So, for example, if you come across an Iron Battleaxe of Scorching, you have a choice. You can enjoy your new battleaxe which will add fire damage to the physical damage you do using it. Or you can disenchant it, and learn how to imbue any weapon with the ability to do fire damage.

In World of Warcraft disenchanting items is necessary to provide you with the reagents, or raw materials, to do other enchantments. Learning the enchantment is done separately, by training or reading a recipe, but disenchantment is still necessary to break down enchanted items into components you can use for other enchantments. Enchantment operates in the domain of creation and destruction, attachment and loss. I can remember feeling many the hesitation as I was about to take an Epic staff I’d used for months and dissolve into Abyss Crystals. Even though I knew that I was going to get a new weapon with a strong enchantment out of it, disenchantment required sacrafice.

Many patients labor under the illusion that the purpose of therapy is to make you feel good. I have always maintained that that is not true. Therapy is not about making you feel good, but rather about learning how to not to feel good. It’s about learning how to experience and tolerate those unpleasant feelings in a different way than we’ve learned to previously. People abuse substances, food, sex, and yes, occasionally video games because they cannot tolerate feelings that don’t feel “good.” Who wants to feel inconsolable sorrow, thwarted passion, grief, terror, or hopelessness?

And so people come to us wanting symptom reduction, not character building; relief, not the raising of unmentionable wishes and fears to consciousness. At first, we often provide those other things to be sure. A compassionate ear to listen, a calming influence, a holding environment. But in the end, therapists are alchemists and enchanters: Nothing new can be created by our patients without something being destroyed. Something must be given up to create something else.

Consider this: Neurosis is like an enchanted armor that we can no longer use. Maybe we have outgrown it. Maybe it never really fit well but it was the best compromise we could come up with. Maybe it buffed up our strength stats when we really needed more intelligence to play our class effectively. For whatever reason, it is no longer helping us, in fact it has created distress.

Symptom reduction alone won’t solve this problem. It may alleviate our distress for the moment, relieve pain enough to create the “space” between feeling and behavior so that we can begin to do the longer-term work.

That’s where disenchantment comes in. We need to take the item, the neurotic conflict, and break it down into the components that create it. What is the wish and the worry? What causes the guilt? Just what are we so afraid of that we can’t look at it directly?

This doesn’t always have to be painful, and therapists shouldn’t use this as a justification for brutality. But to think that the process of therapy is not going to be uncomfortable and difficult; is not going to take some time and hard work is pretty much delusional. If our enchantments could have gotten us any farther we wouldn’t have given them up. Most addicts and alcoholics would have used longer if they could have. If they could have enjoyed one more binge, party or high, they would have.

Insurance companies love to focus on symptom reduction, and a narrow view of what evidence-based treatment really is. Symptoms are problems to be solved, rather than signposts pointing towards underlying issues. And although this is short-sighted, it is understandable: 10 sessions costs a lot less than weekly sessions. And yet, the most recent research I’ve read indicates that psychodynamic therapy is as effective as CBT and other therapies, and in fact more effective in sustaining longterm change.

Bruno Bettelheim, a psychoanalytic thinker, is perhaps best known for his book The Uses of Enchantment. In it he discusses how the themes of fairy tales often symbolize the real emotional and psychological struggles that children go through. Through the projections of stories, children are able to work through their fears in remote and tolerable ways. In a similar way, Klein speaks of the paranoid-schizoid position where the parent is split into good and bad objects, the fairy godmothers and evil witches of fairy tales.

Disenchantment, from a Kleinian lens, leads to the depressive position. It is where we hopefully get to, despite the depressing name, that point when we realize that people are not either all-good, or all-bad, but both good and bad, nurturing and depriving, gratifying and frustrating. In other words, human. The world seems less magical in some ways, and that is experienced as a loss. Sounds depressing, eh? So what is gained?

There is a practice in Tibetan Buddhism called tonglen. In this form of meditation, you begin by touching the tender spot of whatever is sorrowing or distressing to you. Say you’ve lost your loved one. Allow yourself to feel that grief for a moment, really feel it. What an awful wrenching feeling that is. You may reflect that nobody should have to feel what you’re feeling right now. And yet, all over the world, there are those who have felt that, may be feeling it even as you are right now. So you breathe in, and imagine breathing in all of that grief as if for that moment you could take it into your heart so that nobody else would have to feel it. And then you imagine yourself breathing out comfort and security and everything that is the opposite of grief and suffering to the world and to all those in it who need it. You reverse the cycle of trying to avoid pain and grasp pleasure, and in doing so generate compassion.

That is the use of disenchantment; breaking down our fantasies that we can avoid pain and transmuting it into compassion for others. Imagine if you were to really accept that everyone is human and fallible and mortal. If you were able to walk around tomorrow and remain conscious that everyone you meet is dying, would you treat them in the same way as you did today?

Interested in working with me online or in person? Check out the Gamer Therapy and Work With Me Pages!

And if you want to learn more about gaming and psychotherapy, you can always buy my book…

Filed Under: Gamer Therapy Tagged With: addiction, bettelheim, buddhism, children, disenchantment, enchantment, gamers, gaming, klein, managed care, psychoanalysis, psychodynamic, psychology, psychotherapy, Skyrim, therapy, tonglen, World of Warcraft

Occam’s Oyster

December 7, 2011 by langloimsw 2 Comments

The oyster has an amazing evolutionary trick. When a microscopic particle of something or other gets into its soft tissue, it creates over time layer upon layer of nacre, a substance which creates a pearl. What began as an irritant can go on to become a very valuable object.

You are not an oyster.

If something irritates you, you don’t always need to be stuck with it. And although I am a big fan of the cognitive reframe, to use it all the time overlooks that you can often resolve whatever is irritating you by removing it.

Case in point, for the past several years I have used a billing service. They’re great, but there has been something about the process of my patient intakes that irritates me. I have patients fill out an intake form, which they bring in to me. At the same time the billing office has a face sheet they use as well, but they need some information that is not on the face sheet but is on my intake form.

So for the past several years the patient will download my form off the site, fill it out and bring it in to me. I then have to scan the form and fax it to my billing office. To make things more complicated I have several computers and a scanner at home as well as an iPad. You’d think this would make things easy, but I can not seem to get them all to talk to each other the right way to scan something and email it in under 30 minutes. One laptop doesn’t get recognized by the wireless network. The iPad can scan the form but not email it. This has been going on for years, and I had grown accustomed to the irritation as I tried putting on layer after layer of “solutions.” I’d put off scanning the forms until my office asked me for them, which made their work harder, and payments from insurance choppy.

Then it hit me that I am not an oyster. Whenever this irritation came up I had been so focused on trying to make things go more easily, that I had never really taken a few minutes to think about how to make this problem go away. The answer in this case was simple. Instead of having my patients email the form to me, my introductory email to them can instruct them to email or fax it to the office directly. They need regular access to it, and I don’t. They have all of my other administrative paperwork which they keep all safe and secure, so it is actually far easier to have them keep it since they are doing all the billing. I rarely use that initial paperwork, and I’ll always know where it is.

I offer this as a nuts and bolts example of how your therapy practice needs to be evaluated periodically. The whole craziness above is a vestige of when I was doing all of my billing, and something I now realize I was not ready to let go of. And so I just got used to the irritant, ignored it, and hoped it would go away or become less irritating.

We therapists take more irritation for granted than is necessary in our business. We each have a different version of layering on the nacre. One of mine is constantly adding new gadgets and trying to find ways to make work easier, rather than making it go away entirely. I used to spend hours learning the intricacies of a billing software and calling insurance companies, and then I realized I wanted to get rid of the irritation. I researched different services, and finally decided on one which cost a little more, but did a lot more for me. Now I give them 9% of my fee, and in return they keep me credentialed with the insurances I take, send out statements, answer questions from patients and submit all my claims electronically to insurances. Not only do they trap more of my revenue because they can focus on it with more expertise than I, they save me valuable time.

I didn’t value my time as much when I started out, and I am glad I changed that, because I know I wouldn’t have had the time or energy to write a regular blog, do speaking engagements, or write my book this year if I had been chewing on all that paperwork.

So why does it often take us so long to fix systemic problems like this in our practices, or our lives for that matter? I would suggest that the answer is that we don’t value thinking.

I know, sounds crazy on the surface, therapists don’t value thinking? Thinking and thinking about thinking is a big part of our profession. But when was the last time you allotted yourself time specifically to think on something. By that I mean dedicated time where you think through something single-mindedly, not answering emails, talking on the phone, watching television, etc. Most people I coach can’t remember the last time they did that, in fact our coaching appointments are often the closest they come to it.

You don’t have to schedule a specific “thinking time” in your day, although you can certainly do that if it works for you. But in the case above I didn’t do that. Instead I noticed I was getting irritated for the umpteenth time and said to myself, “Ok, stop EVERYTHING, how can I make this irritation go away?” Within a relatively short time of dedicated thinking I identified what the system was, what the problem was, and what the new system would need to be to make the form nightmare go away. Not get less irritating, not more tolerable, but gone.

Look, I’m not saying that everything in life that irritates you can be removed, or even that that would be a good thing. I’m just saying don’t settle for mitigating damage before you’ve tried making the problem disappear. Ask yourself, “am I layering nacre over and over? Is that the best I can strive for?”

Then ask yourself, “am I making time to think, and am I thinking about the things I want to think about when I do?” Sure there are lots of times when you run a business that you’ll need to think about stuff you’d rather not think about; but if that’s how you’re spending the majority of your time then maybe you’re running the wrong business.

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Filed Under: Gamer Therapy Tagged With: behavior change, building your business, insurance, managed care, mindfulness, private practice, psychoanalysis, psychodynamic, psychology, psychotherapy, ROI, stress

Why Ursula the Sea-Witch is My Guru

October 29, 2011 by langloimsw 8 Comments

Ok, so first, let’s be honest, there’s a lot to take issue with in terms of Ursula the Sea-Witch. She definitely carries on Disney’s longstanding history of portraying evil as black, single, independent women, adding to that list women who are considered “overweight” by Western standards of health and beauty. Oh, and she’s sexually aggressive, in that she flirts with King Triton and likes to move in a way that shows she enjoys her body. So yes, I get that Ursula embodies a lot of the negative stereotypes that women and people of color have had to put up with in media.

But if we can look beyond that, I think Ursula has a lot to say that will help you with your business plan as a private practice therapist, and maybe beyond.

I also must admit that Ariel annoys me, especially at the beginning of the movie, which is where one of my favorite scenes is when she makes a deal with Ursula in “Poor Unfortunate Souls:”

Ariel is reluctant to make a deal, because she’ll risk losing contact with her family forever. And Ursula acknowledges this, and says, “Life’s full of tough choices, innit?”

The number one thing I hear from people who want to have a full-time private practice is, “where do you find the self-pay patients?” There are dozens of posts titled that on the Psychology Today forums, and right next to them are the posts saying how much many therapists hate Managed Care and having to take health insurances, with all the rules and restrictions, and low fees.

Yet, when I talk about building your practice to people, I also hear from many people how much they hate promoting their work, and how critical they are of others when they catch a whiff of self-promotion about them. I can’t tell you how many times my blog posts and book blurbs have been pointed at and I have been “accused” of self-promotion. Accused, as if somehow promoting your work and your business is a bad thing.

It’s not.

Look Ariels of the therapy world, life is full of tough choices. You can have a private practice that relies on insurance only, and that isn’t a bad thing. You’ll get to see a range of people who have worked hard to earn health benefits that they want to use, and you’ll have instant diversity of economic status in your practice, the more plans you accept. And the insurance company will list you for free, and you’ll probably build up your practice more quickly. The downside? You’ll make less money, have more complicated paperwork, and time will be spent doing it. And your income will be capped.

Or you can have a private practice where you focus on self-pay, and that isn’t a bad thing either. You’ll have the ability to set and raise your rates, less paperwork and reviews, and have more time to do other things. You’ll still be able to have a diverse practice, using my PB+5 model, and more independence in many ways. The downside? You’ll need to promote your work. You’ll need to give potential patients and colleagues some good reasons why they should forgo their insurance benefits and pay you more money.

To do this you’ll need to spend time working on networking, generating content for your website, speaking, writing a book or making a DVD. And you’ll need to keep doing it. That’s right, you’ll need to consistently promote yourself and your work. The time I used to spend on billing and reviews I now spend on self-promotion, and I do some of it every single week. Sometimes I like it, sometimes I don’t, but nevertheless I do it. Even though I have a wait-list I still do it. And I have watched as several colleagues, who have been in the field for a long time, have stopped doing it. And their practices have begun to dry up, because the phone doesn’t ring as much any more.

You can also try mixing and matching the above a bit, taking some insurances, and doing less promo. Charging more for some patients, and doing more pro bono. All of that is up to you.

But I’m here to tell you you can’t have it all. That’s right, I’m not going to pitch to the starry-eyed that everything is possible. A lot is possible, but everything is not. That’s right, somebody finally said it, there are limits, and you have to make tough choices.

When people work with me, they end up making those choices, and I don’t judge whichever they choose, because I don’t think there is a right answer to this. But I also am pretty outspoken that they are going to have to fish or cut bait. If you don’t like the idea of tooting your own horn, I’m not going to push you to do it, but then don’t complain to me about having to take health insurance. But if you want a predominantly self-pay practice, don’t get self-righteous about self-promotion. First off, self-promotion takes many forms: blogs, advertisements, peer-reviewed journals, telling someone what you do at a party. Everyone in our field does some of that, at least everyone I have ever met. But you’ll need to get off whatever train trip you’re on about how self-promotion is wrong.

There is absolutely nothing wrong with working in an agency full-time. There is absolutely nothing wrong with having a self-pay practice. There is absolutely nothing wrong with taking or not taking health insurance. There are plenty of therapists who are going to take the options that you don’t. But you need to choose something or you can’t have a business plan. And if you don’t have a business plan, don’t try to be self-employed.

Finally, I’d encourage you to get a clock and keep track of how many hours you spend griping about managed care, criticizing your colleagues who market themselves, or asking how to find those self-pay patients online. Because all of that time is time you could be spending on billing, filling out paperwork, writing a book, promoting a talk, in other words building your practice. Complaining to peers is not networking. Worrying about your business is not the same as effort. Don’t confuse the two.

Life’s full of tough choices, go make one.

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

Filed Under: Gamer Therapy Tagged With: building your business, HMOs, insurance, managed care, marketing, private practice, psychotherapy, referrals, ROI, self-promotion, ursula sea witch, Web 2.0

Don’t Run Your Practice Like An HMO

June 18, 2011 by langloimsw 9 Comments

I was surprised today to get a letter from a local insurance company, authorizing payment to me for a session I’d done in September of last year. I wasn’t sure whether to be annoyed or laugh (I decided to laugh) and as I was grumbling about insurance companies I realized that they have taught me what to do and not do with my own billing.

Let’s face it, most therapists don’t like billing and most therapists don’t like insurance. (If you’re not a therapist, read on anyway, you might find it interesting.) Insurance companies are as a rule very difficult to deal with. They make us go through elaborate credentialing processes to join a network that pays us a fraction of our fee. And when we submit claims they often hold on to them for months, delaying our payment. Or they reject the claim because of some technicality, or request a half hour conversation with us to review the treatment so that they can find a reason to stop paying for it. Insurance companies are insulated by layers of administration and bureaucracy, and finding the person to answer the question or authorize treatment can take forever. In fact, the whole premise of insurance has been to have a large enough risk pool of paying clients that they can offset the damages they incur and still make a profit. In short, insurance companies are avoidant, outdated, and hostile to claims.

So why are we just like them?

Therapists groan about insurance companies, and yet we often act just like them when it comes to running our business. We avoid filing claims as long as we can, so that we’ll get reimbursement checks that are bigger and “worth the effort.” We avoid streamlining our billing processes. And we are extremely hostile when it comes to having to file claims to get paid.

Don’t run your practice like an insurance company. Instead, here are some suggestions for you:

1. Don’t delay your billing by unnecessary process. Take a few minutes to look at the way you process bills. Are you writing them down in a ledger, maybe more than one? Do you try to sort things by insurance company rotating different companies at different times of the month? Do you have elaborate formulas for payment plans for your patients’ co-pays? (That’s insurance fraud by the way.) Do you have a calendar that you transfer to your ledger? Or if you have a software program do you enter the same data in several different places? If you are doing any of these things, you’re wasting your time. Come up with one strategy and stick with it, and cut down the number of steps that any strategy you come up with has.

2. Don’t avoid by storing up your accounts receivable. You hate it when an insurance company sits on your claims, don’t do the same thing when it comes to your own accounts receivable. Don’t store up and hoard your accounts receivable to bill “later.” Your patients and you both deserve for you to bill promptly even if it is a $15 co-pay. Don’t drag out your co-pay billing for more than a month at most. Aside from sending a devaluing message to your patients, (“I don’t need that tiny amount of money”) it adds up and can become a source of anxiety to them. Bill out in smaller amounts on a regular basis, and if you don’t, ask yourself what your behavior is expressing about billing. Storing up your accounts receivable may present you with bigger checks later, but irregular ones. For people who know the value of consistent structure, we certainly drop the ball on this one, and then what happens? You see your bank account is low and you say, “I’ve got to do my billing.” And even if you send it out that day, you’ve just set yourself up for a few weeks of anxious trips to the mailbox to see if the money has finally arrived.

3. Don’t treat patient payments like a risk pool. When it comes to billing, don’t rely on a few consistently paying patients to help you avoid billing the rest. If you allow patients to carry a balance set a dollar figure that is consistent across all of them. Mine is $400, because I know that if a patient carries a higher balance than that I may start to get annoyed and that will create static in the treatment. My billing office thinks my limit is too high, but it is what has worked for me and allowed me to be consistent. By all means set your own limit, but don’t have 30 different billing schedules and expectations for 30 different patients! It isn’t fair to the ones who pay regularly, and it also isn’t fair to the ones who don’t. And it also isn’t fair to you. This may work for the insurance companies, but it definitely won’t work for your business.

4. Do your billing every 1-5 days. You heard me, every 1-5 days. None of this once a month or every few weeks or “when I have to” stuff. You’re in business and businesses bill their customers promptly and regularly. And here’s what’s really cool, if you bill every 1-5 days after a while you’ll begin to get paid every 5-7 days. That’s it for this one, 1-5 days, no excuses.

5. Do lose the paper. Not as in misplace it, but as in get rid of it! Many of you are probably saying to yourselves, “he’s crazy. I don’t have time to do all that paperwork every few days!” There’s the problem, you’re still using paper! Start billing electronically, most insurance companies have that capability, and there are plenty of software programs out there that can help. When I used software I would send out that days appointments at 5:30, took 15 minutes. The first few times you will need to spend more time on it by typing in things to the program’s database, but after that it goes pretty quickly. And if you can get in the habit of typing in the first part of the intake the day of the intake, that’s even better.

6. Do use a billing service. I saved the best for last. If you don’t want to do billing yourself, fess up to it. It’s a reasonable business expense to have. I haven’t missed the money I pay to my billing service CMS Billing one bit. The amount of money they have captured for me (including the check from last September) has probably offset what I pay them. In addition, they do all my billing intakes, insurance authorizations, credentialing and customer service for billing questions. The time they have freed up has allowed me to develop workshops, write this blog, and engage in other creative and lucrative aspects of my business. Remember that when it comes to owning a business you need to spend money to make money. Don’t be a tightwad, hire a billing service. Then you won’t have to worry as much about the technology part. But bear in mind that they can only bill as quickly as you report accounts receivable to them, so you still need to do that every few days.

As I write this, 97% of my accounts receivable are under 30 days. I get my money with regularity, and my patients know what to expect when they reach the $400 mark. This is possible for you as well! As this fiscal year draws to a close, take some time to take stock of your billing practices. If you’re acting more like a lending company or an HMO it may be time to change.

Filed Under: Business Tagged With: building your business, HMOs, insurance, managed care, marketing, money, private practice, psychology, psychotherapy, ROI

Epic Mickey and Frittering

May 13, 2011 by langloimsw 1 Comment

The last week I have had a blast playing Epic Mickey; two blasts actually. In the game you’re Mickey Mouse, and your primary tool is an enchanted paintbrush, which sprays two different substances with very different effects. The first is a magical blue paint, which can make invisible things real, and make an enemy in the game turn blue and become a friend. The second is a magical green paint thinner, which can make real things invisible, and thin an enemy into nothing.

There are good reasons to do both of these things, but the unnecessary obstacle in the game is that there is a limited amount of paint and thinner, and so if you use too much too quickly, you have to wait until a cooldown replenishes it, or until you find a power-up. Power-ups, in case you aren’t familiar, are items in the game you can come across that replenish your health, and in the case of Epic Mickey, your paint supply.

The game is a Wii game, and so the motion controller is how you aim the paintbrush to paint or thin. And when I started playing it quickly became apparent that I was going to have to get better at aiming if I wanted to accomplish anything before running out of paint/thinner.

Epic Mickey teaches therapists, gamers, and anyone else who wants to learn through video games some important lessons about living life and frittering away your resources. The game has very simple mechanics, but life often has more complicated ones. Fortunately, this video game can help serve as a meditation on mindfulness and achieving goals.

Lesson 1: Paint Vs. Thinner

When approaching a problem, relationship, or business, it isn’t always immediately apparent whether to add paint or thinner. Do we need to add more stuff or clear some off our plate? Will additional effort reveal opportunities that were invisible moments ago? Do we need to process more with our partner, or less? Perhaps we need to simplify, reduce or focus our practice niche? Maybe we need to remove an obstacle, rather than spray creativity all over the place. One of my favorite paint thinners in real life is Occam’s Razor, which has been often interpreted as “the simplest explanation is most likely the correct one.” Or to put it more like it was originally intended, we should try to avoid any unnecessary pluralities, and tend towards the simpler theories or applications. Sounds like thinner to me, who would have thought Mickey Mouse to be a Scholastic thinker?

And to make things more complicated, Epic Mickey shows us how if we can’t make up our minds we will go back and forth between paint and thinner, undoing anything we may have started and wasting time and effort. So whether we decide we need to add something or take something away, we need to commit to a course of action, or we’ll be confusing dithering with effort. In Epic Mickey so far, I have found that many problems can be solved in a variety of ways, some using paint, some using thinner. I suspect life is like that too.

Lesson 2: Keep an Eye on Your Power Reserves

In the game, you always have to keep an eye on your paint and thinner meters to make sure you pace yourself and don’t run out. They will replenish automatically over time, but slowly. In my business I can attest that this is also true. I usually have a couple of irons in the fire, but I have learned to pace myself. I remember a few years back I was seeing 25 patients a week, supervising three interns and therapists, teaching two classes, taking another, sitting on 2 commissions and trying to write. I had to learn the painful lesson that I was doing a subpar job of every one of these because I wasn’t prioritizing, and perhaps more importantly, I wasn’t allowing time for replenishing myself. Nowadays, I try to pace myself and make time to do fun stuff, like running at least once a week, playing some games, spending time with my family chilling or getting a massage, eat regularly and get enough sleep. Not only are these things rejuvenating, but if I can resist multitasking they block off time so I don’t get exhausted and put out subpar work.

Are you keeping an eye on your reserves? And more importantly, are you willing to give up a few things so that you can devote more time to living life and having fun so you have the energy to do others? I certainly didn’t want to give up any of the activities I was doing, I liked doing them all, just not all at once. Often I hear colleagues say “I just don’t have enough time to simplify and relax,” as if it is a luxury rather than a choice. Sure giving up a couple of things is going to discombobulate you, especially if you’ve learned to pride yourself on being busy. But you won’t run out of paint as often.

Lesson 3: Keep an Eye Out for Power-Ups

In Epic Mickey, time isn’t the only way to replenish, there are treasure chests with power-ups. When I recently defeated the Clock Tower Boss, the way I did it was to keep an eye out for power ups, and sometimes pass up what seemed a perfect shot to get a power-up. In the long run, keeping an eye out for the things that power you, your relationship or your work up will be worth foregoing the perfect shot. This is especially true in relationships: It can be very hard for us to resist zinging that perfect shot, but backing away and taking time to do something replenishing will usually make things turn out more harmoniously!

What are your Power-Ups? Is it a massage, a walk in a botanical garden, meditation, playing Super Mario or spending time with your kids? It’s your responsibility to figure out what these are, make a little time for them regularly, and do them even when you aren’t feeling totally depleted. Pay attention to what happens when you do certain things, eat a certain way, or take something else into your being. Do you double in size and power? Become able to hurl fireballs? Defeat previously impossible monsters? If so, chances are whatever you just took in is a power-up.

Lesson 4: Focus stops Frittering

Last, the more targeted you are in what you’re trying to do, the less wasted energy and resources you’ll have. In life, like in Epic Mickey, you often need to aim for something. Sure, sometimes random efforts yield surprising results. When it does, huzzah, but that’s no excuse for not trying to be focused. Mindfulness is in a large part about focusing your mind and body on something, letting distractions drift by. Use the Force Luke–if you don’t you will probably find yourself feeling depleted, frustrated, and confused as to why.

Yes, focusing means giving up on something else. Frittering means giving up on everything while deluding yourself you haven’t. Parents who become obsessed with quality time rather than choosing a game night are frittering. Saying you want a committed marriage while you’re out every night drinking beer with the buddies is frittering. Complaining about managed care and lower fees rather than marketing your business or helping a forward-thinking candidate is frittering. And there are a thousand other ways that all of us confuse dithering with effort. So pick something and try to focus on it single-mindedly. At least that’s what works for Epic Mickey, and can an 83 year-old mouse who can still defeat monsters and jump over chasms be all wrong? I think not.

Filed Under: Gamer Therapy Tagged With: behavior change, building your business, disney, epic mickey, game theory, gamers, gaming, managed care, mindfulness, nintendo, occam's razor, private practice, psychology, psychotherapy, stress, video games, Web 2.0, wii

Fear Is Where You Start From

May 9, 2011 by langloimsw 14 Comments

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.

Filed Under: Business Tagged With: behavior change, buddhism, building your business, epic therapist, fear, insurance, managed care, marketing, pema chodron, private practice, psychotherapy, self-promotion, social media, Web 2.0

How to Have a 100% HIPAA Compliant Online Presence

January 17, 2011 by langloimsw 38 Comments

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?

Filed Under: Business Tagged With: building your business, confidentiality, HIPAA, managed care, patient privacy, private practice, psychotherapy, Web 2.0

Latest Newsletter is Out!

January 8, 2011 by langloimsw 1 Comment

Some of you have expressed interest in what my monthly newsletter for colleagues is like. So below is a link to the January one. The program I use is Constant Contact. I really enjoyed putting this one together, a combination of health reform, business and gaming stuff. Feel free to subscribe while you’re there. 🙂

January Newsletter

Filed Under: Gamer Therapy Tagged With: building your business, gamers, insurance, managed care, private practice, psychotherapy

The Readiness Is All

December 20, 2010 by langloimsw 2 Comments

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.

Filed Under: Business Tagged With: advent, building your business, managed care, private practice, psychodynamic, psychotherapy

The Demon of Comparison

November 1, 2010 by langloimsw 9 Comments

"Saint Anthony" Tempted by Master of the Osservanza

Have you ever noticed how comparison and resentment go hand in hand? I was reminded of this again when a new bout of it erupted on a listserv I follow.

One therapist began speaking about how s/he was on the phone with an insurance company for a claim, and began to ask them about their salary, and whether they, like the therapist had not seen an increase in it since the 1990s. This prompted a bevy of emails back and forth to the tune of, “Yeah, we should find out how much they make, what they’re salary structure is” and of course the inevitable, “it is terrible that their executives make X amount of dollars.”

Really? Do you really want to be like the executives of a managed care company?

I know that I often blog here about how it is important to cultivate a business sense, so this may sound like a contradiction, but there is a vast difference between learning from businesspeople and emulating the ones we consider are doing unconscionable acts. Therapists often seem to want to have it both ways, we want to have the money and ease we imagine the “fat cats” at HMOs have, but we want to decry them as monsters. You can’t have it both ways, or either, if you want a profitable yet socially just practice.

What I think we often see here is good old fashioned projection, namely, projecting whatever part of ourselves we either find unacceptable or yearned for. Many of our colleagues have strong ambivalence about getting paid for helping, listening, and emotional labor. Sometimes we disown the parts of ourselves that see what we do as valuable, worth every penny, amazing. The way we disown this is to judge it as greed, and project our greediness onto someone else we can despise. The CEOs of insurance companies make great targets, when we look at the financial reports they deliver to their Board of Directors.

But when we project these things on the customer service rep, or care advocate, we miss the mark in many ways. Probably the most important way is that we act out our aggression with a worker who is not making anywhere near the money a CEO makes. And those customer service people aren’t uncaring, their doing a job for a company and often protecting themselves from the assaults they receive via irate therapists all day. Did it ever occur to you that the call the person on the other end of the phone just before you was someone haranguing them about how much they make and how greedy and unfeeling they are?

Look, I’m not trying to make excuses for the bureaucratic nature of managed care. The point I am making is that splitting is a primitive defense, even when the target has a big ol’ bulls-eye on it. More importantly, it doesn’t help your practice.

We have to befriend the part of us that wants to make money by listening to it, and using it to motivate our creativity. If the only way we can access that is by “pinging” off a projection of the “greedy” other, we are staying stagnant. If you are looking to an insurance company, customer service rep, or CEO to recognize you’re value you are wasting your time. Go look in the mirror, that’s who you’ve got to get to recognize you. Can you look that person in the eye and say, “I want to make a good living, and I am valuable?”

Remember, each of you IS a CEO, of your own business. If you aren’t happy with your salary, what are you doing to grow the business that has been entrusted to you by yourself?

Filed Under: Business Tagged With: building your business, managed care, private practice, projection, psychotherapy

The Truth? You Can Handle The Truth.

October 16, 2010 by langloimsw 11 Comments

photo courtesy of informedvote.ca

One of my favorite quotes from Pema Chodron is when she explains the first Noble Truth of Buddhism: “Existence is Suffering.” In her book When Things Fall Apart she writes:

The first noble truth of the Buddha is that when we feel
suffering, it doesn’t mean that something is wrong. What
a relief. Finally someone told the truth. Suffering is part of
life, and we don’t have to feel it’s happening because we
personally made the wrong move.

Patients often come to me to hoping therapy will make them feel good. I tell them that that is not what psychotherapy is for. Psychotherapy is not aimed at making you feel good: Psychotherapy helps you learn how to not feel good, at least the way I practice it. Because the truth is out, there is suffering in the world, and in our lives. Can we learn how to not feel good? How to sit with what feelings arise without eating, starving, cutting, drinking, smoking, sexing our way out of it? Although I didn’t coin the phrase “Don’t just do something, sit there,” my patients often hear it for the first time in our work together.

When I consult with therapists on how to build their practice, or how to use technology, you’d be surprised how much shame, anger and sadness can come up for them. A lot of times they have been avoiding looking at how they do the business part of their work, as if it were completely divorced from their fears of failure, grandiose defenses, and ethical quandries. It takes courage to get to the tender spot that is hurting their business. We have to weave our way past the following bugbears:

“I don’t do this for the money, I do it for the patients.”

“I don’t care if what I tell the insurance company I’m charging is what I’m actually charging, insurance companies are evil.”

“Whatever I have to do to play the game is fine, as long as I can do good work with my patients.”

“I don’t want to know how this billing, marketing, business stuff works, my practice is doing just fine.”

“I don’t know anything about Skype, and I don’t really care.”

One of the great things about working with therapists, though, is that sooner rather than later they hear the defensiveness in their words, and we settle down to not feel good together so we can clear away the shame cluttering their practice. Generally what I find is that their shame comes down to this, see if this internal monologue sounds familiar:

“I have suffered long and hard to get where I am today. I have worked long hours for free, spent money I didn’t have, to get an education that is often undervalued in the world. Even before that, I was always helping people in my life, even when they were supposed to be taking care of me. I waited for someone to notice that I was trying so hard, and finally I gave up. I’m going to have to take care of myself, no one else will. But even though I’ve built my life and work up around that structure, part of me waits with fear for someone to take my work and livelihood away from me. Sooner or later they are going to figure out that I have been faking this adult thing, this independent therapist thing, and then it will be all over, and I won’t have even that.”

If any of this sounds familiar to you, if it is what lies underneath the fears and the avoidance that are gumming up your practice, please read on.

Things were difficult for you, and you didn’t do anything personally wrong to bring this upon yourself. Things will be difficult again, and that won’t be because somebody discovers and punishes you. Suffering is part of life, and we need to pay attention to it, but not personalize it. The clearer you get with this the more clearly you’ll be able to look at your work and business. And the more you do this, the more you’ll face your fears and start to practice in an integrated way, and make money.

On the other hand, if you insist on living your life and practicing your work in accordance with the narrative of fear and entitlement above, all bets are off. Paradoxical perhaps, but maybe you have already noticed how we can manifest irrational fears into real life. Because these fears are the ones that have you stuttering on the phone to UBH during peer reviews, or getting nervous whenever a patient or their insurance company has a billing question. These feelings of anger and entitlement are what make you envious of your colleagues when they try something new in their practice, or promote a book, or launch an online practice. Leave these fears unchecked and your practice will get more rigid, the walls of your office more close, and even if you never get caught for some of the business practices you do you’ll tire yourself out justifying yourself.

I love it when colleagues come to work with me and trust me to tell them the way I see it. I love it when we get honest and the fear starts to go away. I love the relief and the organization that comes in its place. I see priorities shift, new models of working open up, and people rediscover why they like being a therapist. And I see them make more money with less guilt.

You may not agree with everything I write here, and you may not see psychotherapy or business practices the same way I do. No one, least of all me, thinks you should. But my blog is much like working with me in person, I promise I’ll call it as I see it. I think anything less is a waste of your time and money and disrespectful to you. And I won’t collude with you in your disrespecting yourself.

Filed Under: Business Tagged With: buddhism, insurance, managed care, pema chodron, private practice, psychotherapy, shame

Process Schmocess

October 12, 2010 by langloimsw 4 Comments

Photo courtesy of michaelagee.com

We therapists are often a very process-oriented group. We come by it honestly. Maybe we grew up in environments where nobody was heard enough. Maybe we gravitated to the field because we have seen how introspection and exploration have healed the lives of our patients and ourselves. Maybe we learned early on to channel our aggression into verbal aggression. Maybe we want to try to control and slow down the immediacy of our lived experience by putting a webbing of words, a safety net of speech around it. We track the process in our sessions, help the patient process their emotion, encourage them by respecting their process of self-discovery.

Process process process.

I used to work with a lot of elementary school teachers. They were very talented and caring educators for the most part. They’d work long days at school, go home, and sometimes catch themselves saying to their spouses things like, “I need you to get ready for dinner now,” or “Let’s remember to take out the garbage” before their partner reminded them that they weren’t a first grader. By contrast, many of these teachers had husbands who were contractors, plumbers, masons or electricians. They worked long days, but they never seemed to bring their wrenches to the dinner table, use cement to help their kids with their homework, or rewire the television instead of watching it.

They knew how to put their tools down, when they aren’t appropriate to the task at hand.

You probably see where I’m going with this. We use our “self” at work in therapy in very specialized ways. That is very important. But like my teaching friends, therapists tend to approach every task as a verbal processing task. And that just isn’t the way we’re going to fight managed care or build our business. We need to start doing things in addition to talking and listening, we need to use other tools, and we need to start committing to other forms of work.

When I do a workshop on managed care, the first thing I ask people to do is go around the table and whine about it. I want participants to express their feelings of anger, frustration, worry and sadness at how their practice is inhibited by managed care. I listen carefully to each concern, all of them are heartfelt and valid.

I give us 5 minutes.

Then it is time to move on. Let’s talk strategies. Let’s plan how you can use the time you have in the day to market yourself and your work rather than fighting over a check for $60 Let’s get that negative thinking out in the open so you can see how being realistic is really being fatalistic much of the time, and then we can do the opposite and see what happens. I love these workshops, because I watch and literally see the fallen facial expression fall right off their faces. Then there is energy, then there is laughter, then they start trading cards and strategies. We stop processing feelings and start feeling like professionals and business people. They leave feeling renewed and in some cases re-educated, and I get to strike a blow for freedom.

I hope I am always clear that I respect our profession, I respect your calling as a therapist. I do. And I do respect that you have an emotional life worth talking about. But let’s put that on the back burner for a few minutes, an hour, whatever we can start out with. Because I want you to succeed at building your business, and confusing worry with effort and emotion with diligence is not a formula for success. And honestly you don’t need my help worrying, I am sure you do that fine on your own. But enough chat, what are you going to DO this week to build your practice?

Filed Under: Business Tagged With: building your business, managed care, psychotherapy

Secret Formula PB+5

September 22, 2010 by langloimsw 12 Comments

I have frequent consults with beginning or seasoned practitioners looking to get on Medicaid as private practitioners. Their logic on the surface makes a lot of sense coming from their agency backgrounds. A majority of their patients in agency are on Medicaid, and they may want to keep them as they transition to private practice. And many of us went into this work because we want to help a range of people, including the most impoverished or differently abled. These are laudable goals, and I want to assert that they are not incompatible with private practice. But I do think that Medicaid is, at least in terms of building one.

What happens when your patient misses their appointment? With Medicaid you cannot charge them for a missed appointment. And after they miss two or three, you may have the conversation about “are you really interested in treatment?” They say yes, miss again, and you fire them, or don’t call them back and feel guilty and frustrated; or they drop out of treatment feeling like they’ve failed yet again. And in Massachusetts, the newest vendor of Medicaid, Beacon Health Strategies, is trying to change the provider contract to say that you are not allowed to fire them for no-shows! Outrageous, but hey, you signed the contract, so until NASW or APA fights this statewide that is your agreement.

This is such a lose-lose! Private practitioners are not able to make a living, low-income patients are not able to get consistent treatment, and everyone feels like a failure, except the insurance company which pays nothing. But there is a way to build social justice and healthy treatment into your practice right at the beginning, I call it my Pro Bono + 5 session.

Imagine this, you decide that you want to start out in private practice, and while you are building it you want to be able to take referrals from your old agency, which usually has mostly Medicaid patients. So you call them and let them know that you have 2 immediate openings for your pro bono plus 5$ sessions.

Your what?

You explain that while you don’t take Medicaid, you are offering two sessions in your practice where you contract with the patient that as long as they are on Medicaid you will never charge them more or less than $5. You don’t participate in Medicaid, but you won’t bill Medicaid either. You’ll only ask them for a nominal $5 fee payable each week as part of your committment to building a socially just practice. When you meet the patient, you explain this to them, and explain your no-show policy. They keep their appointment, they pay the $5. They miss the appointment, they pay the $5. If they’re sick or unable to make the session, you’ll gladly offer them a phone session, because they’ll still be paying the $5. This is made clear the first appointment, with whatever your normal policy is. You see, you can’t do phone therapy on Medicaid, but on your PB+5 plan you can. For the patient, they are getting a great discount and affordable treatment. For the beginning private practitioner you are getting great clinical experience, including talking about the fee and your therapeutic contract, and feeling like you are doing some diverse work, which hopefully helps you feel more confident in being circumspect when filling the rest of your week. The referring agency gets to win in that they can refer someone immediately. Win-win.

This is not a new concept. Freud created the Vienna Ambulatorium to provide free psychoanalysis almost 90 years ago. We all know that Freud saw many upperclass patients, but he also allotted some time for low-cost or free treatment. You can do the same. And I suggest that you set a fixed number of sessions right at the start of your practice, which will help you later keep the number of full-pay or insurance appointments fixed as well. So what do you think?

Filed Under: Business Tagged With: Ambulatorium, Freud, low-cost therapy, managed care, marketing, private practice, pro bono, psychotherapy

Self-Promotion, No One is Gonna Do It For You..

September 4, 2010 by langloimsw 12 Comments

When I am doing workshops with colleagues or consultations on building a practice, I am often struck by how mortified they become at the thought of self-promotion. And yet, I know too well what they are up against. I have been marketing myself for a while now, in a dozen different venues in multimedia, and it is only recently that I have begun to do so without the negative self-talk or twinges of guilt.

What was I worrying about? Well, in the past I worried that people would say to themselves, “I am so sick of Mike tooting his own horn” or think of me as a narcissist or superficially greedy, etc. Boy did I have to get over that, and if you want to be a successful business owner, you will too!

Back when I worked in a large institution it was fine to hide out, do good work with my patients and bring home a paycheck week after week. But when you decide to start a private practice, you are basically committing to becoming a business. And businesses need marketing.

One of the great things about being a solo practitioner is that your research and development department and your marketing department is the same person, you! Self-promotion is much easier when you have a product or services that you believe in. So I look for opportunities to do the things I enjoy, and then show my colleagues and clients how this adds to my value. When a recent insurance company began stepping up its efforts to bully clinicians, I had no trouble rising to the occasion. I like reading up on parity, researching and educating myself about the business climate, and thinking about how language can be used by HMOs to disempower therapists. And after a few conversations with colleagues, who were clearly looking for a fresh approach to that problem in their practice, I realized that I had something of value to offer. So now I’m doing workshops on the subject and loving it.

It is very tempting to trade the structure of an institution for the imposed structure of managed care. Don’t do it! If you do you have only yourself to blame. As I tell my consultancy clients, you need to remember that the most important difference between you and the insurance company reviewer is that you have better things to do with your time. The reviewer is a salaried employee who is paid to call you and conduct these clinical reviews. Whether you are on the phone 5 minutes or 50 minutes, they get paid. You don’t. In your time you could be:

Seeing another patient.
Devising a workshop strategy
Networking with a colleague
Being the first to call a potential referral back
Writing your newsletter or blog
Designing your website
Writing your google ad
Writing an article for your professional magazine
Depositing checks in your bank
And more!

The way the intimidation tactics work is that HMOs are banking on your need to buy into a system, even a system of oppression, rather than your own. Yes, they may say they are not going to pay for any more sessions, that’s their mission. So make the call brief, and use the time to self-promote some other part of your business.

Self-promotion scares many of us even more than HMO reviews, but self-promotion ultimately pays better and gives you more freedom, motivates you to stay current and innovative, and puts you back in the driver’s seat rather than the victim seat. I want to know: What can you do to toot your own horn today?

Filed Under: Business Tagged With: HMOs, managed care, mental health parity, self-promotion

Remember the Alamo, er TOPS!

September 1, 2010 by langloimsw Leave a Comment

I was just reminded by Liz Z. on a poll comment (there’s still time to weigh-in on the one-question poll btw, and read the interesting comments) about BCBS alliance with BHL consulting group and the TOPS. I think this was a timely reminder for myself and any who are feeling discouraged at our work.

When BCBS first rolled the TOPS out, we were all flooded with propaganda about it, how it was going to revolutionize things. And there were the subtle incentives (a higher rate for those who filled out the form) and the not so subtle disincentives (those who did not fill out these forms would be required to do more onerous authorizations ultimately.) I remember the time I got back the results with one of my higher functioning patients, recently unemployed, who had endorsed “had unwanted thoughts or images,” and was considered at high risk for psychosis. I remember trying to embrace the TOP process and then I remember feeling alternately angry and insulted.

It seemed like the TOP was here to stay, and then it wasn’t.

The TOP failed to stick because we refused to do them. We objected on legal grounds, questioned its validity, and most importantly took action by refusing to do them. Websites like this one sprung up:

And now a year later, the TOP is rapidly becoming a distant memory. I think the moral to the story is that we can effect change. I hope that we can galvanize ourselves in the coming months and not take the “you can’t fight city hall approach.”

Filed Under: Business Tagged With: activism, managed care

Be proactive, read your mail!

August 4, 2010 by langloimsw Leave a Comment

So if you are a Tufts Provider, October 1st is a special day. What? You don’t know what I am talking about? Well I know for a fact that as of October 1st if you submit a B&W copy of your paper claim form, it will be rejected. Yep, no red CMS-1500, no checky. I am sure hundreds of my colleagues are going to find this out on October 20th, when they receive rejected claims letters, and they’ll be ranting about the system. Yes, the system sucks, but it is the system you choose to get paid by, so read your mail.

The above does not really effect me, I have a billing service and we submit all of our claims electronically (CMS-billing.com btw, they rock). But I wanted to share that with you for a couple of reasons. First, to hopefully save you some headaches, but second, and more important to give an example of how keeping your business in the black requires dealing with what we therapists often consider “mundane.”

We’re all about bearing witness to people’s suffering; helping them transform their lives; healing relationships; changing behaviors that hurt them and others. That’s the lofty profession we want to see ourselves in, and yes, it is a lofty profession. But we’re also in business, and if you don’t get with the program you’ll be out of business. When you get provider updates from the companies you work with, READ THEM. Yes, they are boring, but they will save you time and money. It takes 5 minutes to read the “60-Day Notifications” articles in the Tufts newsletter for example. A lot less time then it takes filling out a claim, mailing it, waiting 3 weeks, finding out it was rejected, calling to be sure what that weird code means, talking to someone, scrambling to find some forms, realizing you don’t have them, running to Staples to order more, waiting for them to come in, and resubmitting so that you can get paid 3-6 weeks later because you still use paper claims.

Bear witness to your own suffering; transform your life by working smarter; heal your relationship with your inner businessperson whom you need to VALUE; and change your behavior around the administrative aspects of your business, it is hurting you and those around you (unless you never ever gripe to your spouse about the paperwork, get nasty on a call to a service rep about something you should have known about, or get distracted when you are sitting with a patient because you haven’t been paid yet.)

5 minutes. Read your mail.

Filed Under: Business Tagged With: HMOs, managed care, mindfulness

Many Happy Returns

August 1, 2010 by langloimsw Leave a Comment

It may be a coincidence, but when I turned 40 I began to hear the term ROI a lot. For those of you who may not have heard of ROI, it stands for “return on investment.” There is a technical definition of it on Investopedia, but I think I figured out why it kept leaping to my attention last week when I was speaking to someone about dragging my feet on a piece of work I had committed to do.

“I’m just worried that this will be a waste of time.” I was talking about return on investment.

I have always been a worrier about time, and like Marvell always hear Time’s Winged Chariot. But it has usually been from a fear-based perspective, and somehow, ROI has gotten me thinking more about finitude from a more positive perspective. Yes, there is a limited amount of time in my life, so what am I going to do with it? Am I going to spend it angsting about the ever-decreasing amount of it, or am I going to embrace my agency and be mindful of how I am investing myself in life? My colleague, psychologist Susan Giurleo is an excellent power of example for this. We both have psychotherapy and consultation practices, and have watched as health insurers have begun to put the squeeze on providers while continuing to enjoy their own salaries stability. I have become a founding member of AMHP, a group of mental health providers who are becoming activists about this issue. When I asked Susan if she would post an entry on our group discussion she was ambivalent about it, and in her explanation of why she was ambivalent she wrote:

1. I think major efforts will generate a low ROI. We can fight a cut, but

the nation is heading toward insuring more people for less money. Writing is

on the wall for all health care, not just mental health.

2. I’ve found putting my energies into diversifying my income stream has

huge ROI. I’m working toward a business model where I don’t take insurance

because I want to be paid for everything I do at the time of service.

Accepting managed care is just a bad business plan for so many reasons. I’d

rather slide my fee and get the money in hand than have to bill and haggle

with a third party.

There was that phrase again, ROI! Susan’s point makes good business sense, but it also makes good life sense. And the beauty of it is that each of us get to evaluate ROI for ourselves! I can wholeheartedly understand her point of view, and at the same time find that investing my time and effort into AMHP brings returns for me that I find very valuable. I have already begun to meet more of my local colleagues throughout my work on this. I actually enjoy reading about antitrust laws, and discussing this and the business side of my practice. I find political activism very rewarding, and get more energized to research and advocate for AMHP. It has me talking more with colleagues about another interest of mine, working with therapists to make better use of technology like social media. We live in an historic moment in that never before has it been so easy to share so much information with so many mental health providers across the world so quickly! This has been utilized by the health insurance industry to our detriment, but it is accessible to us. And not just in fighting the good fight against managed care. Technology can bring great ROI on our practice. I have used Skype to conduct psychotherapy in Asia, and have supervisees who “beam in” regularly for their appointments. And if you don’t have a website, if you don’t “invest” yourself in the internet, I am convinced that you will see diminishing returns in your practice.

As therapists we invest in our work, and more importantly we ask that our patients invest in it as well. But therapy should never be an act of completely blind faith for a patient, they can and should consider what the ROI will be on the hours and dollars spent. We have an obligation to be able to explain why the work is worth investing in. And we need to get more comfortable with the idea of ROI, because if we don’t define our ROI the insurance companies will. They already have: the briefer the treatment needed to get symptoms reduced to a least common denominator, the better the ROI. As one clinical reviewer at UBH told me last week when I said that a patient’s GAF of 70 was their highest the past year: “Well we need to look at the fact that this is probably their baseline and end treatment.” Oh, really? I guess I should just say to them, “sorry, you can’t become any more insightful, have greater well-being according to UBH. You’ve plateaued at ‘meh,’ so don’t let the door hit you on the way out. My solution to this problem is to say to UBH, sorry, not enough ROI for me, I’m out of your network. Will I need to work harder in other areas to generate revenue? Yes. But will I ultimately have a better quality of life without having to play such profane games, you betcha. Thinking in terms of ROI has made me more confident, more thoughtful about what I take on for work, and what I pass by.

So let me know, what brings you your highest ROI in your work, your life? What brings the lowest? When that car cuts you off, what is the ROI on teaching them a lesson with your horn or finger? When you feel a sense of presence and accomplishment with a therapy’s deep work, remind yourself that you are experiencing a moment of mindfulness. Mindfulness of ROI. Don’t miss it, and when you notice opportunities for ROI act on them, because as Jack’s mother in “Into the Woods” says, “opportunity is not a lengthy visitor.”

Filed Under: Gamer Therapy Tagged With: managed care, mindfulness, psychotherapy, ROI

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Remember the Alamo, er TOPS!

Be proactive, read your mail!

Many Happy Returns

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