Why Ursula the Sea-Witch is My Guru

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.


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Don’t Run Your Practice Like An HMO

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.



Epic Mickey and Frittering

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.

Fear Is Where You Start From

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

I was pleasantly surprised.

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

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

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

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

Fear is the place you start from.

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

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

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

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

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

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

How to Have a 100% HIPAA Compliant Online Presence

Fort Knox photo courtesy of Flickr

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

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

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

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

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

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

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

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

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

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

2. Life is temporary, the internet is forever.

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

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

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

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

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

5. Understand how email works.

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

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

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

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

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

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

Latest Newsletter is Out!

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

The Readiness Is All

Engraving by R. Brandard


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

Shakespeare, Hamlet. Act v. Sc. 2.

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

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

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

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

Ok, so what are you getting ready for?

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

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

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

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

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

Get ready.

The Demon of Comparison

"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?

The Truth? You Can Handle The Truth.

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.

Process Schmocess


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?