How to Get Taken Seriously as a Mental Health Professional

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.

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Post to a Young Therapist

I’m a big believer in twofers.  When you run your own business, twofers are essential.  So when I get several emails about a topic I try to craft a post in response.  Recently I have been getting emails from many therapists or therapists in training who want advice on how to pursue a career as a gamer therapist.  Many of them grew up playing video games and have a lot more comfort and familiarity with them than their therapists who have been around for a bit.

Take Claire for example, who has graciously allowed me to share an excerpt from her email to me:

For most of my life, both video games and service to others have been passions of mine. I’ve recently been working at a game company in XYZ, and have been immersed in the gaming culture more than ever. The more I see it (and experience it first-hand) the more I see a need for therapists who can address the issues so many gamers face as a result of their passion.

Before today, I had no idea if anyone had pioneered this field of study, of if there was even a place for it. And then I found you. A quick perusal of your website tells me that you and I are very much aligned in our beliefs about how games affect us, and why they matter. Seeing that you have crafted this job for yourself inspires me to look further into the possibility of knitting together these passions of mine.

Note the use of the word “passion” here.  I hear from these younger folks how their interest and curiosity around video games and technology in general is met with skepticism and often hostility.  Supervisors turn into lawyers before their very eyes and begin every conversation about technology with the words “HIPAA” and “liability.”  The only question asked in the exploration of patient’s video game is “how many hours are they on the computer?”

Part of the problem with this disconnect is that many up and coming therapists become inadvertently ashamed of the fact that they are gamers themselves.  The implicit or explicit pathologizing of video games and tech use shapes the behavior and expectations about whether discussing gaming, or even using it as an intervention, stops before it begins.

Those of us who have been in the field for a while can often become set in our ways.  We can act as if education and the workplace haven’t changed much since we started our practice.  Insulated in our office and routine, we stick with the phone, maybe email, and play therapy games that have changed little since the 70s.  With this stance we are not prepared to work with patients in the 21st century, let alone supervise 21st century trainees.

If you are training to be a therapist, here’s what I recommend if you want to be a gamer therapist:

1. Start from Within

Repeat after me, “It is okay to experience excitement and enjoyment when I am working with patients.”  Somewhere along the line our graduate programs have begun to give you the message that you are supposed to be an evidence-based automaton with little emotional investment in treatment.  I have had students who have heard dozens of times in their training ideas like “emotional detachment,” and “inappropriate boundaries;” yet not once has anyone talked to them about feeling excited and enjoyment in their sessions.  Even trainees doing play therapy express guilt or fear about getting “caught up” in the play.  You’d think we were supposed to spend our entire careers with dull, depressing people!  Allowing for a range of emotional experience with patients means the whole range, including excitement and fun.  So if you are going to be a gamer therapist, start building your capacity to enjoy yourself in sessions.

2.  Create A Gamer-Affirmative Environment

Did you know that research has suggested that 1 out of 4 comic book readers are age 65 or older?  Yet how many offices have comic books for their adult patients alongside People and Time?  The same is true for video games.  Geeking up your office and waiting room sends the message that you don’t equate video games or technology with “toys.”  In my waiting room I don’t have comic books currently, but I do have Wired magazine and titles devoted to video games.  Many conversations have begun as a result.  I also have a Deathwing statue and other game-related memorabilia.  Recently someone saw a Post-It I had with the word Katamari on it.  I had made a note of the game to remind myself to check it out.  That Post-It was all it took to begin a very excited and meaningful conversation about the game (which has a free App, by the way.)  The smallest changes to your office can convey that you are interested.

3. Try (and I mean play) lots of different video games

This is the fun part, usually.  I have the major game platforms and am always trying one or two new games a week.  If a patient mentions a game in a session, I make a note to try it ASAP if I haven’t already.  Sometimes this requires discipline, because like most people I don’t like every sort of game.  But each game I test out helps me understand the patient better.

4. Have video games in your office

I have always had handheld video game consoles in my office, but in addition I have an XBox 360 as well.  I don’t think you can be doing contemporary play therapy well without it.

5. Disclose that you play video games

The fact that you have game consoles probably implies this a bit, but let’s be explicit. Regardless of age, 64% of Americans play video games, and the percentage is much higher under 40.  So if you have played video games, disclose that you have.  If you have a supervisor who sees that disclosure as more akin to “I smoked pot as a teen” than “Yes, I saw Star Wars” run away.  Video games are an art form not a controlled substance, and there is a big difference between those two conversations.

6. That said, be on the lookout for countertransference.

Whether you like or hate, play or avoid, video games, you need to be mindful of the reasons why and when you talk about aspects of it.  If your patient is telling you that they managed to fish up the giant sea turtle in WoW, it is an empathic failure to say, “Yeah I got that last week, isn’t it cool,” rather than to reflect to them what that says about their persistence and discipline.  Note any feelings of competition you have (or don’t have) and wonder about it.

7. Get good supervision, even if you have to pay for it privately.

One of the downsides of licensure having a (in MA) 2 year post-graduate supervision requirement before you get your independent license is that it inadvertently sends the message to fledgling clinicians that after two years you don’t need it any more.  That is not true.  I encourage new therapists to consider ongoing supervision of some sort to be a business expense to build right into your practice.  I had the opportunity to have weekly supervision for free at my workplace for 12 years.  That sort of job benefit has gone the way of the milkman in many places today.  This means you’ll need to buy some.

If you buy private supervision, remember that it is a different experience from your earlier or agency experiences with it.  This is not your boss, you are hiring them.  Hiring people means interviewing them, and screening them for fit.  If they are technophobic they are not going to be a good fit for a gamer therapist, so it is important to let them know your pro-technology and gaming stance from the beginning.

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.

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When Wallflowers Attack

Back in graduate school, my group therapy professor once said to me, “early risk-takers are often scapegoated by the group.”  This comment came on the heels of yours truly taking a risk in the group, a group of psychotherapists in training.  I learned two things in that group class on that day.  The first was that early risk-takers are often scapegoated.  The second was that we therapists can be just as cruel with our comments as anyone else.

This is something that many of my supervisees encounter when they start to put themselves out there, especially on the interwebs.  They are stunned when the blog post they write elicits comments that are sometimes shocking in their nastiness.  They are confused as to why this happens, and what to do about it.  If you are beginning to use social media to build your psychotherapy practice, write newsletters, prepare a public speaking campaign or just write a blog, this post is for you.

The internet has made it easier to be both impulsive and anonymous, and emboldened some people to hurl invectives.  I call these people the wallflowers.  These are the people in any given group who are afraid to take risks or stand out, and resent those who are brave enough to do so.  They are quietly resentful, and more often than not envious of people who are not quiet.  I’m not talking about introverts here, but rather a particular group who stand on the sidelines seething.

These are the people who send you a nasty email at 2:00 AM criticizing your post for a spelling error, or the folks who text really ugly comments to you after you post something on a listserv they don’t like.  They’re the people who make personal attacks on your workshop evaluation in the guise of constructive criticism, or bait you in discussion groups by deliberately misconstruing your words.  Yes, I’m not making this stuff up, all of these things and worse have come at me by email, Twitter, Facebook, blog comment, and text message.  The majority of the time it will be behind the scenes of whatever arena you’re in, so that you can see it and the larger group can’t.  Consciously or unconsciously, wallflowers are counting on you not passing these barbs on to the larger group.  Nobody likes a tattletale.

So what do you do about them?

First, take a second and calm down, and note that the intensity of your response is probably an indicator that this is out of the ordinary.  Next, try to find a trusted friend or family member that you feel comfortable sharing it with, and ask them what they make of it.  Supervisors are often really helpful here.  Often they will react more strongly then you did, which gives you another clue its a wallflower attack.  Your inclination may be to try to learn something from the comment.  I’m going to say something that may go against the therapist grain here–Dismiss the comment and the wallflower.  Don’t bother trying to make this into a growth opportunity, there are plenty of other growth opportunities out there for you.  Don’t give this your energy.

In my experience this is very hard to do, because therapist wallflowers have a lot of skills to hook you.  They bring their therapeutic arsenal and try to come at you as a therapist, by analyzing or interpreting you.  Don’t fall for it.  Just because you both speak the same language doesn’t mean you have to have a conversation with them.  Therapy is a specialized and voluntary form of conversation, and anyone who tries to inflict this on you unasked is using their Jedi therapy powers for ill.

This is your reminder.

This is the price you will have to pay for being an innovator and a risk taker.  Early risk takers are often scapegoated.  You didn’t do anything wrong, you were just putting yourself out there.  And every time you do that, you will run the risk of a wallflower attack.  Don’t overprocess it, move on.  And definitely don’t let it stop you.  Remind yourself that the reason they had anything to attack you about is because you’re doing something they wish they could, creating.  Anyone can ping off a blog post, or fire off a Tweet in reaction, but it will only be a reaction, not a standalone.

Remind yourself that your ideas are precious.  I’m not trying to sound New Agey here.  What I mean is that the fact that you had something to put out there is not to be taken for granted or underestimated.  You could have not had the inspiration for that workshop or podcast, but you had it.  All over the world there are people who have not given awareness to ideas, throughout history millions of good ideas have never been expressed or seen the light of day.  Not you.  You did it!  And if you stop taking risks the wallflowers win, and the prize is one less idea in the world.  Yippee.

I know this can be hard to do, trust me.  And the technology we have today has made it even easier for wallflowers to attack.  It’s sort of like that sense of invincibility drivers get when they are encased in the protection of their cars.  Shake it off.  Share it with someone you trust for perspective.  Dismiss it.  Stay focused.  You can take time to smell the roses, but don’t get distracted by the wallflowers.

 

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21st Century (Psycho)education

Whether you’re a psychotherapist, an educator or a parent, sooner or later you will be involved in the facilitation of growth through learning.  The bad news is that most of us were educated in the 20th century, when education was largely modeled on the 19th century.  The view of literacy then was narrower, standardized and often monolithic.  The good news is that technology today can help us invigorate learning as never before, often by using the mechanics or design of video games and social media.

Before we press on, it is time to choose your own adventure!  I encourage you to ask yourself and answer this question: Is education inevitably like a daily spoonful of cod liver oil?  That is, do I believe that it is something that is routine, unavoidably unpleasant the people need to just suck it up and deal with?

If you answered yes, click here to stop reading this post and go to Mordor, where you can play a free MUD with other denizens of gloom and doom.

If you answered no, read on to find some examples of how simple game mechanics can revolutionize a curriculum.

1. Game Patches

Game patches are supplementary, downloadable game content that patches into existing games to either fix bugs or introduce new content into existing games.  One example was the famous Burning Crusade from World of Warcraft, which added another world of play, new races to create characters as, flying, and many new quests to challenge players.  More recently, Minecraft added patches to include jungles (1.2,) fixed multiple crashes (1.2.4,) and made cats more impatient and eager to sit on things (1.2.5.)  Much of the patch content comes from user experience comments, and players often know and eagerly await for patches for weeks in advance of their arrival.

Introducing content into classroom settings can benefit from this approach.  First off, polling students during subject matter about what aspects of what they are learning would they like to know more about?  What ways can learning or behavioral problems be debugged?  For example, elementary school teachers can hype up the class before rolling out Grade 3.5, at the halfway mark of the year, and include in this patch a total restructure of seating plans, allowing new class configurations and addressing problems in a way that starts to be both expected and exciting.

In terms of curriculum, from kindergarten to college, most educators have some lesson plan, and previewing content of upcoming lessons can generate interest and engagement.  This can range from creating a funny trailer on YouTube with teasers for the next lesson, to releasing hints about upcoming problems and subject matter.  This can include contests to name upcoming characters, for example the characters involved in mathematical word problems, or residents of new areas about to be unlocked and explored in geography.

In school-based and outpatient therapy groups, where is often a psychoeducation component, group leaders can initiate a countdown before patching new content or welcoming new group members into the group.  For process-oriented groups, members can be invited to debug and modify the design of the group to deal with challenges or conflicts in the group.  I remember a really interesting version of this that a colleague of mine went through in her internship.  We were at an outpatient mental health clinic, and although it was not languaged as a patch, her co-leader had her join the group for the first several weeks as a participant-observer.  She attended the first 4 groups without speaking, and as week five approached there was much discussion and projection from other members about what she would say when she finally spoke.  She was in essence the new content “patched” into the existing group, which introduced change, and new transference while maintaining some group stability and continuity.

2. Talent Trees

If we can just get beyond the tendency towards and linear thinking in curriculum, I am convinced that this intervention could be extremely effective.  First, for those of you who are unfamiliar with the idea of a talent tree, here’s an example:

 

In many games, players have some choices about how to specialize in the area of talents.  As they progress through levels, they acquire talent points to spend on unlocking different talents.  So if an educator can be flexible in the order of learning certain topics, students can choose to specialize in learning something first or second.  Let’s take Literature, would you like to be an Arcane Satirist, Epic Voyager, or specialize in Bloodmagic Murder.  If you want to progress through the first talent tree, you will need to read and complete assignments involving Gulliver’s Travels, the second, The Odyssey, and the third MacBeth.

If you are doing psychotherapy we already have a version of this, it’s called DBT.  In it people focus on unlocking talent points in the trees of mindfulness, interpersonal effectiveness, emotion regulation and distress tolerance.  Which does the patient feel that they would benefit from working on first?  Which do you recommend?  For adolescents especially, this can make the difference between engaging in treatment and just another boring worksheet.

Other ways to use talent trees effectively can include:  Helping gamer couples unlock skills to better communicate or improve their sex lives; helping parents focus on and prioritize specific behaviors to work on with their children; a template for an emergent adult’s first career search; and systematic desensitization of a phobia.

These are just two ways that we can use both the technology and concepts behind it effect change therapeutically and educationally.  Can you think of others?

 

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The Perilous Price of a Good Living

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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Unplanned Obsolescence: Rethinking Play Therapy

Recently I ordered a copy of Call Of Duty: Modern Warfare 3, which I plan to try this week.  As I have mentioned in a previous post, I am not easily interested by first-person shooters, but as a gamer-affirmative therapist I can’t let my low interest get in the way of educating myself.

I once calculated that by a conservative estimate I had played approximately 27,000 games of Uno in my decade working in a public school as a clinical social worker.  I drove around with a ton of board games and a sand tray as well.  I had learned the value of play therapy at the first placement I ever had as an intern, from Winnicott’s squiggle game to the infamous Talking, Feeling, Doing Game.  This is all a roundabout way of establishing my “street cred” for valuing play therapy.

Back then, I would go home from work, and many times play Legend of Zelda: Majora’s Mask on the Nintendo 64.  My roommate at the time liked to hang out with me while I played and we chatted about life, education (he was a teacher) and politics.  He also liked to imitate the fairy guide in the game, and would often cry out, “Listen!” and offer a couple of tips.

In all those years, it never occurred to me that I could have played those games at school if I’d had an office (and some years I did) or that there was a disconnect between what I was doing with the students (card playing) and what they were talking about (Nintendo, XBox, Playstation.)  I could hold a conversation with them about these things because I played them in my spare time, but the idea of playing them with my students didn’t register as, well, therapeutic.

I am not alone in this.  Many if not most play therapists are not inclined to play video games with their patients, and it is time to rethink this.  When 97% of the boys and 94% of the girls we work with play video games, it is no longer an outlier.  But there are a few fallacies which I think get in the way of play therapists integrating play therapy into the 21st century.

One I hear frequently is that video games don’t require imagination, or offer projections to explore.  But I think this is contempt prior to investigation for the most part.  The proliferation of video games is itself the best evidence that there is imagination going into each generation of games, which are produced by imaginative people who must have been able to develop their imagination in part through video games.  And we don’t start each session making our children build their own dolls and dollhouse from scratch.  We use available tools that do to an extent always structure and limit the imagination.  For example, why does the dollhouse have a pointy roof and two floors?  This is limiting, and in fact didn’t represent 90% of the urban population I worked with at all.  And few play therapists would avoid using Elmo puppets on the grounds that it limits the imagination of the child, even though Elmo is clearly an icon of popular culture.

In fact, play has often had its inception in the popular culture of the time.  We may take chess for granted now, but when it came into being it was a reflection of a medieval monarchy, with kings, queens, and bishops.  Yet play therapists often fall prey to nostalgia, if not luddism, and maintain that there are certain games and play that are relational and therapeutic, and others, usually the modern ones, are not.

This brings me to what I suspect is another reason we resist using video games in play therapy, which is the therapist’s fear of being incompetent or failing at the unfamiliar.  Years of training in a traditional educational model have taught us to silo down in our area of “expertise” as soon as we can.  We “major” in psychology or social work, go to graduate school for advanced specialization, and basically get to a point where we can work in a routine and structured environment.  For years we get in the habit of certain forms of play therapy: Candy Land, Chutes and Ladders, cards, chess, dollhouses and telephones.  These are easy and portable, but more importantly perhaps, we know how to play them, so we can not be “distracted” by the game, or lose by design if we want to build the kids self-esteem, and otherwise feel in control of the play situation.

It’s time we work through this resistance.  People can and do have conversations while they play video games, and video games are in themselves social media.  There are plenty of metaphors to explore in and after video gameplay.  Angry Birds is rife with themes of anger, different abilities, and protecting the innocent and defenseless.  Call of Duty can give rise to expression of competition, drives, and the hunger for destruction or cooperation.  And a recent (to me) favorite, Demon Souls, is a tone poem on isolation, yearning to connect, and persistence in the face of despair.

I’m sure I’ll get comments arguing that video games are inherently violent as well.  To which I would respond, just like Battleship and the card game War are inherently violent.  We have become insulated to the violence in them, and it may not have the graphic sophistication of video games.  But the next time you play Battleship ask yourself what you think happened to all the people on the battleships that sunk?  The game doesn’t come with little lifeboats, you’re drowning people.  Play therapy does not avoid violence in its expression.

Virginia Axline, one of the founders of modern play therapy, had 8 guiding principles for play therapists:

  1. The therapist must develop a warm, friendly relationship with the child, in which good rapport is established as soon as possible.
  2. The therapist accepts the child exactly as he is.
  3. The therapist establishes a feeling of permissiveness in the relationship so that the child feels free to express his feelings completely.
  4. The therapist is alert to recognise the feelings the child is expressing and reflects those feelings back to him in such a manner that he gains insight into his behaviour.
  5. The therapist maintains a deep respect for the child’s ability to resolve his own problems if given an opportunity to do so. The responsibility to make choices and to institute changes is the child’s.
  6. The therapist does not attempt to direct the child’s actions or conversation in any manner. The child leads the way; the therapist follows.
  7. The therapist does not attempt to hurry the therapy along. It is a gradual process and is recognised as such by the therapist.
  8. The therapist establishes only those limitations that are necessary to anchor the therapy to the world of reality and to make the child aware of his responsibility in the relationship.

 

Nowhere in there does it say, the therapist sticks with the tried and true games s/he grew up with.  To my colleagues who are ready to decry the death of the imagination and lesser play of video games, I think Axline said it best:  “The child leads the way: the therapist follows.”

Following in the 21st century means having Gameboys and Playstations in our repertoire.  If we don’t keep learning and using technology in our play therapy, we may find ourselves in a state of unplanned obsolesence.  Am I saying we should stop playing Jenga and Uno?  No.  But if our patients are looking for video games amongst the chess sets and dollhouses, perhaps they are telling us something we need to pay attention to.  Just because we don’t know how to play a game doesn’t exempt us from learning it.  And what a gift it can be for an adolescent to experience themselves as more competent and talented by an adult!  So many of them come to us having been labeled as “failed learners,” and we have the potential to help them experience themselves as successful teachers, of us.

Those of us working in agencies and schools need to resist the temptation whenever possible to use the excuse of needing to be mobile or budgetary constraints.  Video games are now as portable as a Nintendo DS PSVita or Smartphone.  And the price of a video game system is not so prohibitive as to be a given.  The real reason we often don’t advocate for video games at the agency or school is our own bias that they are somehow less valuable as therapeutic play media.

I anticipate that this will meet with resounding criticisms from the “play-is-going-to-hell-in-a-hand-basket” crowd, but I’m really interested in hearing from colleagues who have managed to successfully integrate video games into their play therapy.  What are your success stories?  What have been some challenges you’ve had to overcome?  Do you schedule online play sessions?  How do you manage the noise in an office suite?  I’m really interested in your experiences.

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Harriet At Forty-Eight

If you never read the novel Harriet the Spy, I hope you will ASAP.    My hope is that most children, parents and therapists have had a chance to read it already, because it has a lot to teach us about digital citizenship.  You can get it on Amazon here.

Harriet spends a lot of time writing down things in her notebook.  Truthful things.  Unflattering things.  And one day the notebook falls into the hands of her classmates, who read these things, and respond to her with anger.  What I find interesting is the way Harriet’s friends, teachers, and parents respond.  Their initial response is to take, or try to take, Harriet’s notebook.  Of course Harriet gets another one.  That’s not the problem.

Harriet the Spy was published in 1964.  According to Wikipedia, at least one variation of the technology of the notebook had been around since 1888, and there are examples of its common usage in the early 1900s.  This technology was prevalent long before the 1960s.  No one says to Harriet that she has a “notebook addiction,” although her usage of it becomes problematic.  In fact, her redemption in the book also comes from the same technology of the written word.

One of my favorite moments in Harriet the Spy comes in Chapter 14, when Harriet has her initial appointment with a psychiatrist.  As they settle down to play a game, the psychiatrist takes out his analytic pad:

Harriet stared at the notebook.  “What’s that?”

“A notebook.”

“I KNOW that,” she shouted.

I just take a few notes now and then.  You don’t mind, do you?”

“Depends on what they are.”

“What do you mean?”

“Are they mean, nasty notes, or just ordinary notes?”

“Why?”

“Well, I just thought I’d warn you.  Nasty ones are pretty hard to get by these days.”

“Oh I see what you mean.  Thank you for the advice.  No, they’re quite ordinary notes.”

“Nobody ever takes it away from you, I bet, do they?”

 

This vignette illustrates how the clinician is not above or apart from technology.  Harriet’s psychiatrist uses it himself.  And his response to her struggle and worry about using technology is an approach I’ve come to see as key:  He doesn’t try to restrict her from using the technology, he engages her around its use and thinking about its use.  He actually gives her a notebook, and then respects her usage of it when he lets her leave the office without taking it back or asking to see it.

He then recommends that her parents talk to the school about allowing her to use technology to amplify her thoughts and expression there, via the school newspaper.  He also suggests that they use technology in the form of a letter written by Harriet’s old nanny to give her some advice and connection.  Many will say that Ole Golly’s letter is the pivot point for Harriet in the story, but I’d suggest that the pivotal moment comes when the mental health practitioner doesn’t demonize technology (the notebook) or pathologize its usage, but rather leans on technology as an avenue into the patient’s forward edge transference.

Technology, as Howard Rheingold reminds us, is a mind amplifier.  It can be used to amplify our memory in the form of notes, for example.  It can also be a voice amplifier, for better or for worse.

If Harriet was around today, I imagine she would be on LiveJournal, perhaps with her settings on private, but on LiveJournal nevertheless.  In fact, her LiveJournal notebook would probably be more secure than a notebook carried around on her person without encryption.  But maybe she’d also be on Facebook, Twitter, and Tumblr.  And unless she had parents or teachers who talked to her about digital literacy, she might not know or care about privacy settings or mindful use of technology.

Every day, on Facebook or Twitter or other social media, people young and old post, and “drop their notebook” to be read by hundreds or thousands of people, who can amplify the notebook even further by liking, pasting, sharing or tweeting it.  By comparison, Harriet’s class of 10-15 students seems paltry.  When an adolescent complains about her ADHD medication on her status, or when a parent tweets how proud he is of his Asperger’s child, these nuggets of information, of expression, of identity formation are sent out into the world and amplified.  Our work as therapists needs to be to help our patients understand the significance of what they are about to do to themselves and others when that happens.  And to do that we need to understand the technology ourselves.

Few of us would consider giving Harriet a notebook as “feeding her addiction,” or giving her a hair of the dog that bit her.  Yet, we level such technophobic claims on the social media and technology of our time, trying to focus on technology as an addictive substance rather than as a tool, and pathologizing its use far too quickly and easily.  And we often join technophobia with adultism, when we try to intrude or control the use of technology by children and adolescents (note that I said “often,” not “always”)

When you look at some of the stories Harriet prints in the school newspaper, you have to marvel at the bravery of the educators in that school!  How many of school administrators would allow entries like “JACK PETERS (LAURA PETER’S FATHER) WAS STONED OUT OF HIS MIND AT THE PETERS’ PARTY LAST SATURDAY NIGHT.  MILLY ANDREWS (CARRIE ANDREWS’ MOTHER) JUST SMILED AT HIM LIKE AN IDIOT.”  Can you imagine the parental phone calls, even though the parents were both the behavioral and quoted source for this story?  Can you imagine kids being allowed to experience communication and learning with this minimal form of adult curation?  But also, can you imagine parents saying that the problem is allowing access to the technology of writing a newspaper, and that the idea of a school paper should be abolished?

When you think about it, we live in an amazing era of the amplification of human thought and expression.  Our children will need to learn how to manage that amplification in a way we still struggle to understand ourselves.  I remember one notebook I dropped, when I was managing a staff of guidance counselors.  I was very frustrated with the response of one of them to something, and wanted to share that with my supervisor.  I thought it would be important to share my emotional response to this with someone I understood to have the role of helping me sort this stuff out, and I was being impulsive and cranky.  I ended up sending the email to the staff instead.  Boy, did that torpedo those relationships.  But I did learn a lot about how to pay more attention to the power of technology, and that part of being a good digital citizen requires thoughtful use of ampliying your words and ideas!

Most of us probably have a notebook-we-dropped story we’d rather forget, but we need to remember them and share those stories with the up and coming generations as cautionary tales, and examples of good and poor digital citizenship.  Ole Golly tells us, “Remember that writing is to put love in the world, not to use against your friends.”  Writing, a technology we have come to understand a bit better since Gutenberg, can be used for good or ill; but we don’t ban it.  Now we are all learning, albeit uncomfortably at times, how to handle the newer technologies of social media, digital communication, and video games.  It may be a bit utopian to suggest that texting/tweeting/gaming/Facebook/blogging is to put love in the world.  But the alternative seems to be that while some of us ignore, avoid or fear it, other people, governments and corporations will learn how to use it against our friends.

Embedded in Harriet the Spy is a quote from Lewis Carroll, which aptly describes where we find ourselves in the 21st century of social media: “‘The time has come,’ the Walrus said,/’To talk of many things:”  Indeed, the chatter can be deafening, impulsive, hurtful and confusing.  But the solution is to choose our words carefully, not to stop talking altogether.

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Attention, Distraction & Creepers, Oh My!

 

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Failing Better

 

Play is a vital part of being a person, and failure is a vital part of play. One of the things I’ve been thinking about lately is the connection between autonomy and failure. When children, adolescents and adults for that matter play video games, they fail a lot. In fact, according to Nicole Lazzaro, 80% of the time we are playing video games we are failing. What other activities in our daily lives can we say that about?

Education, on the other hand, at least the traditional model, grades us on a 100% model very differently. If you get 70% of a test or a class material “correct” you get to pass it. If you get 69% it needs to be done over again, or you don’t get any credit at all. This system actually flies in the face of what educators and therapists know about learning, that it is a matter of trial, error, course correction, trial, error, course correction… and so on.

This in some ways answers a question I have often wondered about: Why are we willing to be failing 80% of the time in video games, and so reluctant to risk failure in “real life” even a fraction of the time? One answer the percentages above point to is that education often stacks the deck against us, effectively rendering any mastery of content below 70% as a failure. This failure has attached to it, shame, sense of time wasted, futility, and hopelessness.

But there is another aspect of failing in video games that I think we need to pay attention to, and that is the role of autonomy. In a 2009 study, Jesper Juul found that people prefer to play games where they feel responsible for failing. The majority of those surveyed didn’t want to attribute it to bad luck, but something the did or didn’t do. They wanted a sense of autonomy in their game play, not luck. Conversely, they didn’t want to feel victimhood either, but rather optimism.

I have been playing a game on the iPad called Incoboto which has given me pause to reflect on fun failure. (An aside for gamers who have also played this and Dark Souls, have you considered Incoboto as a cutified version of Dark Souls, trying to link the fire and bring light to a darkened solitary world? Just saying..) The game has a series of puzzles which one needs to solve in order to collect star pieces to feed to the kawaii sun Helios following your character around. There have been a few places where I got “stuck,” and spent in my opinion too much time having to throw something exactly the right way. This highlighted for me the subjective experience I had for the majority of gameplay, that I was being challenged but would eventually be able to overcome the unneccessary obstacle. On those occasions I called getting stuck, I began to experience feelings of victimization and externalize responsibility. The game was not “being fair,” it was too hard, there was a “bug” in it making the ball not land “right.”

What helped me persevere was both compelling graphics and gameplay, but also a sense of faith in the game. Ok, sometimes I cheated too, by looking up spoilers on the game forum. In those moments, you could say that I was giving up the voluntary attempt to overcome an unnecessary obstacle of the game. But, and this is what’s important, I was also ceding my sense of autonomy. It’s a weird balancing act, in one case I didn’t look at the cheat to find the solution as much as to get reassurance that what I was trying was the solution. But even though I was exercising my digital literacy here, I was also giving up for the moment my sense of autonomy, and agency.

Failure, and tolerance of failure is a subject thing, which is why Lazzaro’s presentations illustrate zones, not points, of fiero, frustration, relief, and bored. Everyone has variations in how they experience emotions, and failure in video games. And if I didn’t keep that in mind, I might feel very disheartened when I read this review of Incoboto:

“Great mix of platformer and puzzle game, very smooth learning/difficulty curve, and quite a nice gameplay experience too”

Now I am not going to get into a discussion on norms and trends and the importance of betas, because my point here is to compare and contrast the experiences of failure in video games and education.

Education in our country is trying to overcome some serious design flaws of its own. Children and adolescents are given tremendous responsibility for their performance without a commensurate amount of autonomy. This creates a culture of victimhood. Rather than noticing they got more than half of something right, we flunk them. Rather than setting meaningful individual goals, we create industrialized curriculum. And if we do give someone an individualized set of goals in the form of an IEP, we label them as learning disabled first to justify it!

We need to improve the quality and experience of failure in schools. Because video games don’t occur in a separate reality from the point of view of our minds. That mind/body split of Descartes has been debunked for ages, and yet we’re still talking about “real” life. The reality is that mastering challenges and fun failure creates a feeling of optimism, which neurologically and emotionally improves our ability to learn in the future. If we think we are capable of solving a problem, we will keep at it. Therefore, we need to foster a sense of autonomy in learning. The minute we start talking about “my special needs child,” we are taking away their autonomy.

Am I saying we should expect everyone to perform the same at school or other work? Not at all, I am saying we should be better curators of children in learning environments, and let them have less stigma around failure. In a real sense, every child should have an individualized education plan, because we are moving (hopefully) out of an industrial model of education.

As a therapist and educator who has worked in and with school systems and parents for nearly two decades, I have struggled with this frequently, both within myself and with my patients. The language of diagnoses and learning disabilities is a language I speak all too well, and I have unintentionally colluded at times with parents and systems who use it as shorthand for, “my kid can’t ___.” Maybe if failure was more tolerable and fun in school we wouldn’t be so quick to adopt these identities, and maybe if we curated environments that allowed for more autonomy we would notice different varieties of success as well.

The other night I was on a Minecraft server I participate in, founded by educators and edutechs for their children. Several of the kids were on and chatting when I logged in, and shortly thereafter this huge flame war erupted. Capital sentences of “I HATE YOU” flew across the screen. Kids stormed out of the chat room, returned, then logged off again. Some of the young moderators were instigating further conflict, while others were earnestly trying to figure out why people’s feelings had been hurt in the first place. From the therapeutic point of view, they were failing miserably, exhibiting poor social skills, dysregulated affect, and poor impulse control. It took a herculean act of will not to jump in and actively curate this group and allow them to exercise their autonomy.

They kept at the chatting, and over the next several minutes they began to collaborate on understanding what had happened. This did not have the grown up version of a happy ending where the aggrieved parties apologized and made up, so much as the group told one party that they appreciated the apology and weren’t ready to accept it then (my translation) told a second party to stop instigating in the guise of defending someone, and encouraged the third to come and build something to take his/her mind off of it.

In my mind, the fact that this took place in a game environment where failure is destigmatized and autonomy is presumed made it easier for people to keep at the challenge until it had been resolved “enough.” There was no adult who was forcing them to stay on and work at this, they were voluntarily engaged. There were several halting starts and stops of chat. But social emotional learning was occurring.

This in my opinion is an example of “failing better,” and I think this is a skill that not only can be translated from video game experience, but desperately needs to. The more we except failure as an essential part of learning and work, the less stigmatizing it will be. The less we stigmatize failure, the more we encourage autonomy and optimism. Autonomy and optimism make you a better learner, a better collaborator, and a better worker. Personally I think the world could use a lot more of that.

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Worth a Thousand Words?: Infographics on Video Games

 For those of you who haven’t heard, Pinterest is a pinboard style of social media which emphasizes visuals.  Recently I was trying to learn more about it and how it might apply to the psychotherapy/psychology field.  So far I can see possibilities:

DBT- Using Pinterest to create worksheet boards, or better yet boards of images which provide self-soothing for distress tolerance.

Behavior Charts which are visual and available instantly from home instead of going home in a book bag and being forgotten.

Virtual Comic Books to help adolescents learn and practice sequencing and pragmatic speech.

Screenshots of video games that can be shared by gaming patients with gamer-affirmative therapists.

Psychoeducation Tools for a variety of issues, including the above example.  Click on the image to see my board on Infographics for video games and gaming.  They are not intended as professionally vetted research, and you’ll not the heading encourages viewers to check out the research.

There are obviously things to be concerned about, such as privacy and how best to bring Pinterest into the therapeutic session, office and process.  Pinterest is not HIPAA-compliant, for example, so would a link sent via hushmail be secure enough for some uses?  How might we make sure our patients could use this powerful visual tool in a way that did not disclose what health information described what they were using it for.

What do you think?  How might we use this powerful visual medium to enhance our treatment with patients in an best-practice way?

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